374601939-5-31-2023-08-AS-DNGN-CSCW4V-20230531165811

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601939
Report Date: 05/31/2023
Date Signed: 05/31/2023 04:58:19 PM

Document Has Been Signed on 05/31/2023 04:58 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	SPECIAL FRIENDS-SAGEWOOD		FACILITY NUMBER:	374601939
ADMINISTRATOR:	WOJCIECHOWSKI, MICHELLE		FACILITY TYPE:	735
ADDRESS:	13411 SAGEWOOD DRIVE		TELEPHONE:	(858) 312-1687
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY: 6		CENSUS: 5	DATE:	05/31/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Staff Virginia Pacheco and Administrator Michelle Wojciechowski		TIME COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Staff Virginia Pacheco. LPA then met with Administrator Michelle Wojciechowski, who arrived later during the visit.

Today's visit was in response to an LIC624 Unusual Incident/Injury Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 05/25/2023). According to the LIC624: During a community outing on 05/21/2023, Client #1 (C1) was briefly left unattended by staff; they did not suffer any harm or injury as a result. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]

During today’s visit, LPA performed a facility tour / welfare check, verifying that C1 and other clients in care were safe / unharmed. LPA also collected copies of pertinent records and interviewed relevant clients and staff.

During the visit, LPA sought to examine C1’s LIC602 Physician’s Report (or equivalent medical assessment), but the licensee did not possess such a document on C1 (which was confirmed by the administrator).

According to C1’s Face Sheet and San Diego Regional Center (SCRD) Client Placement Referral (dated 02/09/2022): C1 was diagnosed with “mild intellectual disability.” Staff interviews revealed that while C1 was a high-functioning client, they were not safe to be in the community without staff supervision.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SPECIAL FRIENDS-SAGEWOOD	FACILITY NUMBER: 374601939
	VISIT DATE: 05/31/2023

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[CONTINUED FROM LIC 809]

According to client and staff interviews: During the 05/21/2023 outing at the beach, Staff #1 (S1) and Staff #2 (S2) were operating two separate vehicles and preparing to bring clients back to the facility. C1 informed S1 that they were going to use the public restroom, which S1 acknowledged understanding. However, when C1 returned to the parking lot to rendezvous with staff, S1 and S2 had both already departed in their respective vehicles, carrying the other clients with them. S1 was the staff person directly assigned to / responsible for C1 during the outing. However, as they were departing the beach, S1 assumed C1 was with S2, while S2 assumed C1 was with S1. C1 was instead left behind. C1 used their personal cell phone to call staff to inform them to come back and pick them up. C1 was alone/unsupervised for approximately 10 minutes.

Based on record review and interviews, a preponderance of evidence exists to show that: a) for a brief period, Licensee did not provide supervision necessary to meet C1’s safety needs; and b) Licensee did not possess the required Medical Assessment on C1. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the licensee.

An exit interview was conducted with Wojciechowski, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/31/2023 05:15 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/31/2023 05:10 PM

Created By: Dang Nguyen On 05/31/2023 at 04:34 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SPECIAL FRIENDS-SAGEWOOD	FACILITY NUMBER: 374601939
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/30/2023 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	80078 Responsibility for Providing Care and Supervision: “(a) The licensee shall provide care and supervision as necessary to meet the client’s needs.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	As of the date of deficiency issuance, S1 was no longer employed at the facility. Licensee explained they already (prior to CCLD’s visit) planned to update their outing procedures to: a) require that clients only travel in the vehicle belonging to their assigned staff person, b) require clients to enter public restrooms with either staff or a peer nearby, and c) encourage clients to bring their personal cell phones (if they own one) during outings. Licensee planned to retrain their staff on these new procedures on/around 06/03/2023. Licensee agreed to E-mail LPA a copy of the training sign-in sheet by the POC due date.
	8 9 10 11 12 13 14	Based on records and interviews, licensee did not provide supervision necessary to meet the safety needs of 1 of 5 clients (C1), which posed a potential safety risk to persons in care.	8 9 10 11 12 13 14
Type B 06/30/2023 Section Cited CCR80069(b)	1 2 3 4 5 6 7	80069 Client Medical Assessment: “(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client’s medical assessment.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to coordinate with C1’s responsible party and physician, as needed, to obtain an updated LIC602 Physician’s Report on C1. Licensee agreed to E-mail a copy of the updated LIC602 to LPA by the POC due date.
	8 9 10 11 12 13 14	Based on LPA observation and staff interview, for 1 of 5 clients (C1), licensee did not keep on file documentation of a medical assessment, which posed a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

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:

Lizzette Tellez

LICENSING EVALUATOR NAME:

Dang Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

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