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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880584
Report Date: 10/04/2022
Date Signed: 10/04/2022 10:48:32 AM

Document Has Been Signed on 10/04/2022 10:48 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:NAVIN CAREFACILITY NUMBER:
361880584
ADMINISTRATOR:MARTIN, USHAFACILITY TYPE:
735
ADDRESS:12631 ALGONQUIN RDTELEPHONE:
(760) 240-5161
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 5CENSUS: 1DATE:
10/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Ariana Torres, CaregiverTIME COMPLETED:
10:48 AM
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility 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 from the facility on October 2, 2022. LPA met with caregiver Ariana Torres and explained the purpose of the visit.

The SIR documents that on October 1, 2022, the Licensee and staff #1 were arrested on a abuse allegation of resident # 1 (R1).

Inquiry into this incident included conducting a tour of the facility to assess for any Health and Safety concerns. LPA observed that three (3) out of four (4) residents were removed from the facility. LPA was advised per S2 that the Licensee and S1 were not at the facility and could not return until the last client was removed. LPA confirmed that the Licensee and S1 were not at the facility by conducting a tour of the facility. LPA interviewed resident #4 (R4). LPA observed the new placement facility's staff pick up R4 and R4's personal belongings during the course of the visit.

There were no health and safety concerns observed during this visit. Additional information will be required before the closure of this incident.

No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to Torres.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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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