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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800222
Report Date: 04/06/2023
Date Signed: 04/06/2023 09:46:39 AM

Document Has Been Signed on 04/06/2023 09:46 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:11772 JUSTINE WAYFACILITY NUMBER:
361800222
ADMINISTRATOR:SATTIEWHITE, KOLICEFACILITY TYPE:
735
ADDRESS:11772 JUSTINE WYTELEPHONE:
(760) 991-6602
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 4DATE:
04/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Shanellreya Knowles, caregiverTIME COMPLETED:
09:50 AM
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On 04/06/2023 at 9:18 a.m. Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced for a case management visit . This case management visit is in response to a special incident report (SIR) that this agency received from the facility on March 22, 2023. LPA met with caregiver Shanellrreya Knowles and explained the purpose of the visit.

The SIR documented that on March 20, 2023, resident # 1 (R1) was agitated with staff # 1 (S1), which resulted in R1 assaulting S1. The SIR further documented that S1 threatened R1 in response to being assaulted.
Inquiry into this incident included conducting a facility tour to assess for any Health and Safety concerns. LPA was unable to interview R1 because they were at school. On March 23, 2023, LPA conducted a telephone interview with the administrator about this incident.

LPA advised Knowles that, at this time, this incident requires further investigation. Possible follow-up telephone calls, requests for copies of relevant documents, and visits are necessary before reaching investigative findings.

No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to Knowles.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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