374603495-7-3-2023-08-AS-DNGN-CTE2SV-20230703173946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603495
Report Date: 07/03/2023
Date Signed: 07/03/2023 05:40:26 PM

Document Has Been Signed on 07/03/2023 05:40 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:	SUBLIME LIVING II		FACILITY NUMBER:	374603495
ADMINISTRATOR:	LUIS RAFAEL DELAROSA		FACILITY TYPE:	735
ADDRESS:	829 BANNEKER DRIVE		TELEPHONE:	(619) 741-1515
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92114
CAPACITY:	5	CENSUS: 3	DATE:	07/03/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Caregiver Mariana Martinez and Program Manager Monica McDade		TIME COMPLETED:	05:45 PM

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Mariana Martinez. LPA then met with Program Manager Monica McDade, who arrived later during the visit.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 06/15/2023). According to the LIC624: on 06/13/2023, Client #1 (C1) eloped from the facility (i.e. left staff line of sight). [See LIC 811 Confidential Names List for a description of person identifiers used in this report.] C1 was brought back to the facility later the same evening, unharmed/uninjured.

During today’s visit, LPA performed a brief facility tour and welfare check on the remaining clients in care, finding no immediate safety concerns. (As of today’s visit, C1 was no longer a client of the facility. They had moved out on 06/30/2023). LPA also reviewed C1’s pertinent care records and interviewed relevant staff.

According to C1’s Face Sheet and records from San Diego Regional Center (SDRC), R1 was diagnosed with “ADHD-hyperactive,” “anxiety,” “disruptive mood dysregulation disorder,” “oppositional defiant disorder,” “autism,” and “mild intellectual disorder.” According to the facility’s general Absentee Notification Plan, staff must notify law enforcement within 2 hours of an elopement. Licensee also authored a customized “Plan of Action for [C1] (Elopement),” which described multiple possible activities and interventions, which staff could try, to calm C1 during periods of anxiety.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023

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: SUBLIME LIVING II	FACILITY NUMBER: 374603495
	VISIT DATE: 07/03/2023

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[CONTINUED FROM LIC 809]

Records and staff interviews revealed: On 06/13/2023 around 5:00 PM, C1 felt overwhelmed/upset following a personal phone call. C1 expressed to staff that they felt anxious and wanted to go on a walk to calm down. Staff #1 (S1) accompanied C1 on such a walk. However, during the walk, C1 quickened their pace and tried to run away from S1. S1 phoned facility management while trailing behind C1. As C1 approached a busier street, S1 decided to stop following to avoid provoking C1 running towards traffic. Facility staff timely phoned law enforcement, C1’s responsible party, and SDRC. Law enforcement successfully located C1 later that same evening. C1 was returned to the facility unharmed/injured.

Based on the evidence collected today, there does not exist a preponderance of evidence showing that licensee did not create a plan of care for C1, or that licensee did not give needed observation to C1, or that licensee did not follow its Absentee Notification Plan, or that licensee did not meet reporting requirements. No deficiency was cited for the above incident. Also, no deficiency was observed or cited during today’s site visit.

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

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023

LIC809 (FAS) - (06/04)

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