<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800222
Report Date: 08/14/2023
Date Signed: 08/14/2023 11:40:27 AM

Document Has Been Signed on 08/14/2023 11:40 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:
08/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Shanellreya Knowles, house managerTIME COMPLETED:
11:46 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to conduct a Health and Safety case management visit. This case management visit is in response to a special incident report (SIR) that was received by this agency on August 14, 2023. LPA Nickolas met with house manager Shanellreya Knowles and explained the purpose of the visit. This case management visit included a facility tour and interviews with relevant parties.

The SIR documents that on August 8, 2023, resident #1 (R1) foot was struck by a vehicle while crossing the street. LPA Nickolas' interview with staff #1 (S1) revealed that R1 was away without leave (AWOL); S1 followed R1 in the facility vehicle to ensure that R1 was safe. S1 stated that they turned on their hazard lights as R1 crossed the street, and an unknown individual driving a dark colored vehicle swerved around the company van and hit R1's foot. LPA Nickolas' interview with R1 revealed that R1 could not recall the incident. R1 showed LPA NIckolas a red mark behind their ankle and stated they received it from the car. R1 expressed no health or safety concerns about living at the facility.



No health and safety concerns were discovered, and the investigation into this incident is closed.

No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to the Knowles.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1