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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424637
Report Date: 06/15/2023
Date Signed: 06/15/2023 01:26:08 PM

Document Has Been Signed on 06/15/2023 01:26 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:NEW DISCOVERY RESIDENTIAL SERVICES IFACILITY NUMBER:
366424637
ADMINISTRATOR:DONNA WELDONFACILITY TYPE:
735
ADDRESS:26278 DATE STREETTELEPHONE:
(909) 280-9644
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 6CENSUS: 4DATE:
06/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Vivian Francisco - AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility to conduct a case management on a deficiency observed on 05/22/2023. LPA met with Vivian Francisco who was informed of the purpose of today's visit.

The deficiency is issued in relation to complaint number: 56-AS-20230518141057 that was filed under the incorrect facility. The complaint allegation was Staff did not properly supervise client resulting in elopement. On 04/19/2023, the Department received an incident report from 04/17/2023 that Client 1 (C1) eloped from the facility and was taken to a local hospital. The incident report further stated that facility staff had been counseled on preventing C1’s elopement tendencies.

During today's visit, LPA reviewed records and received proof of correction. A Letter of Deficiency Citations Cleared was issued during today's visit. No new deficiencies were observed during today’s visit. An exit interview was conducted where this report was discussed with and provided to Licensee.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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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Document Has Been Signed on 06/15/2023 01:26 PM - It Cannot Be Edited


Created By: Anna Bueno On 06/15/2023 at 01:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NEW DISCOVERY RESIDENTIAL SERVICES I
FACILITY NUMBER: 366424637

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2023
Section Cited
CCR
85078(a)(1)

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(a) In addition to Section 80078, the following shall apply:
(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.

This requirement was not met as evidenced by:
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Licensee shall provide updated procedures for staff to prevent future client elopement.

As of today's visit, this POC has been satisfied. The incident report submitted to the Department on 04/19/23 stated that staff had been counseled regarding C1's behavior.
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Client succesfully eloped from the facility when facility staff was not able to keep client within their line of sight. This poses an potential health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
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