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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920020
Report Date: 10/16/2024
Date Signed: 10/16/2024 11:24:06 AM

Document Has Been Signed on 10/16/2024 11:24 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FORASTERA HOME CARE INCFACILITY NUMBER:
345920020
ADMINISTRATOR/
DIRECTOR:		CENTENO, CRISELDAFACILITY TYPE:
735
ADDRESS:360 FORASTERA CIRTELEPHONE:
(916) 519-7474
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY: 4CENSUS: 2DATE:
10/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Criselda Centeno, LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On October 16, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a Case Management visit. LPA met with Criselda Centeno Licensee and informed her the reason for the visit. LPA received a Serious Incident Report from the facility stating one of the residents had an episode and had to be taken to Kaiser Emergency Room for evaluation. The resident was referred by Alta Regional Center, but Alta failed to disclose seriousness of the resident's medical issues.

Resident (R1) was very agitated on Monday October 14, 2024 to the point where the physician, his behavioral doctor came to the facility to speak with the parents. The parents were trying to transition him to the facility since this was his first time live away from his parents. R1 arrived on September 16, 2024 and has been very agitated on and off since arriving. The parents stated R1 has long period of confusion with aggression. The resident's primary diagnosis is Agitation and urinary retention. He also has grand mall seizures, At the time of the incident, R1 was pacing around the facility trying to damage furniture by throwing pillows from the couch in the neighbors backyard. After that he relieved himself on the walls of his bedroom. By this time, R1 was not following directions It was when R1 tried to run away from the home is when staff call 911. Sac PD arrived and tried to talk with him and when they could not communicate with R1, he was place in the back of the police car and taken to the emergency room for evaluation.

Currently, R1 is at Kaiser North Sacramento. The hospital informed the facility R1 is now stable but would require a medical evaluation. He is on a 51/50 hold until he receives the evaluation. The behavioral doctor wants the resident to stay in the home if a 'Behavioral Intervention Plan' is incorporated which would include a Restraint Plan to keep him safe. Doctor will develop a plan and train the staff of this plan. This plan consist of a 3 touch maneuver to restrain the resident and it would be an individualized plan for him. The parents and the facility are in agreement with this plan. The facility will have 2 staff working on every shift that have been trained.

To continue see 809-C...
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FORASTERA HOME CARE INC
FACILITY NUMBER: 345920020
VISIT DATE: 10/16/2024
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Licensee is requesting to place 'Delay Regress' in the kitchen to slow down the resident's aggression. The facility currently is developing an ' Individualized Emergency Intervention Plan, (IEIP) that will be reviewed by Alta Regional Center.

LPA is requesting the facility to keep Licensing updated on all incidents. LPA also would like to have a meeting with Alta Regional Center to set parameters with the Restrain Process that is to be followed.

Per California Code of Regulations, Title 22, no citations were issued.

An exit interview was conducted and a copy no this report was given to Cris.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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