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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603352
Report Date: 12/28/2023
Date Signed: 12/28/2023 02:17:17 PM

Document Has Been Signed on 12/28/2023 02:17 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
RIVERSIDE, CA 92507
FACILITY NAME:MOUNTAIN SHADOWS OUTREACH SERVICESFACILITY NUMBER:
374603352
ADMINISTRATOR:FLOR ANGEL REALFACILITY TYPE:
775
ADDRESS:970 LOS VALLECITOS BLVD, 140TELEPHONE:
(760) 743-3714
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY: 150CENSUS: DATE:
12/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:SUPERVISOR, FRANK SALASTIME COMPLETED:
02:28 PM
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On December 28, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a Case Management Health and Safety visit, and met with the Supervisor, Frank Salas. LPA Mixson introduced herself and explained the purpose of the visit.

On December 27, Community Care Licensing received information stating a Staff (S1) showed aggressive actions toward a Resident (R1)in care while at the Day Program. During the Health and safety visit today it was reported that S1 was terminated and no longer works at the day program.

LPA Mixson toured the facility, along with the Supervisor and made observations pertaining to the health and safety of the residents in care.
There are no imminent health and/or safety concerns observed at the time of visit. The LPA requested and received pertinent documentation. The Supervisor stated the staff in question is no longer working at the program and provided documents to demonstrate this.

LPA Mixson did not observed any health and/or safety hazards inside or outside of the facility at the time of this visit. LPA observed all facility utilities to be on and operating without issue. The LPA assessed the available food supply and observed there was a variety of food types for snack for residents while at the day program. The medications were locked in the nurse's station and inaccessible to the residents in the day program.

Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were observed or cited during today's visit.

An exit interview was conducted and a copy of this report was provided to the Supervisor, Frank Salas.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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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