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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920113
Report Date: 12/12/2024
Date Signed: 12/12/2024 05:04:47 PM

Document Has Been Signed on 12/12/2024 05:04 PM - 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:ASA CARE HOMES INCFACILITY NUMBER:
345920113
ADMINISTRATOR/
DIRECTOR:
SANTIAGO, ANNEDREAH JOYCEFACILITY TYPE:
735
ADDRESS:7720 GUENIVERE WAYTELEPHONE:
(916) 709-4612
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 4CENSUS: 3DATE:
12/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:25 PM
MET WITH:Lavinia Dokonivalu and Hazel Natividada, caregivers TIME VISIT/
INSPECTION COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on an incident report submitted to the Department on 12/7/24. LPA met with Lavinia Dokonivalu and Hazel Natividada, caregivers, and asked to speak to Administrator, Annedreah Santiago.
LPA spoke to the administrator by phone and stated the reason for today's inspection. LPA observed client (C1) sitting on the couch in the common area.

Administrator provided LPA with an update on the incident reported on the incident report. The Administrator stated she reported the information contained on the incident report to Alta California Regional Center (ACRC), who initially advised her to report the incident to law enforcement and to the Ombudsman's office. The Administrator stated she did report to both agencies, but was told by each agency this incident doesn't fall under their jurisdiction. ACRC then instructed her to submit a suspected abuse report (SOC341) to Adult Protective Services (APS).

The Administrator stated she is meeting with ACRC tomorrow, 12/13/24, to discuss client's Individual Progress Plan and will complete the report by then and email it to the Department also.

The Administrator stated (C1) is doing a lot better emotionally now that all test results were received but is still not able to recall the actual date the incident occurred. The Administrator stated she and the ACRC Behaviorist do believe (C1's) account of the incident, and (C1) is able to leave the facility unattended.

LPA stated due to the circumstances described in the incident report submitted to the department on 12/7/24, the case should be referred to any other appropriate agencies. LPA also stated she would provide an update to her manager also. LPA toured the interior of the facility to ensure (3) clients were present.

There are no deficiencies cited in this report. Exit interview with Hazel Natividad. Copy of report provided to the staff.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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