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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603818
Report Date: 04/18/2019
Date Signed: 02/20/2024 08:13:00 AM

Document Has Been Signed on 02/20/2024 08:13 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:EUBANK CASTLEFACILITY NUMBER:
374603818
ADMINISTRATOR:ANETA STANEK DE LA ROSAFACILITY TYPE:
735
ADDRESS:1528 SANGAMON AVENUETELEPHONE:
(619) 825-6473
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 6DATE:
04/18/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Kevin Marvel, House ManagerTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted a case management visit regarding two incident reports received in the office on 04/15/2019 for Client 1 (C1) and 04/17/2019 for Client (C2). LPA Holmes was greeted at the front of the facility by House Manager Kevin Marvel. The purpose of this visit was to follow up on the incident reports/ AWOLs of Client 1 and Client 2. (See LIC 811 Confidential Names)

Incident report dated 04/15/2019 regarding the AWOL of C1 on 04/12/2019. The staff contacted the sheriff immediately to inform them that the C1 left. The client does have a history of AWOL. The client is not able to leave the facility unassisted. Facility has an AWOL plan in place. Facility also has an individual plan for C#1. Facility staff followed C1 down several streets. The sheriff met with C1 at the gas station that is close to the facility. Staff met them there as well and was able to speak with C1 and brought C1 back to the facility. LPA Holmes reviewed pertinent information from C#1 file and received copies of information regarding C#1.

Incident report dated 04/17/2019 regarding the AWOL of C2 on 04/15/2019. The staff contacted the sheriff immediately to inform them that the C2 left. The client does have a history of AWOL. The client is not able to leave the facility unassisted. Facility has an AWOL plan in place. Facility also has an individual plan for C#2. Facility staff did not know C2 whereabouts on the day C2 left. The sheriffs department ended up picking C2 up from the streets and took C2 to the hospital on 04/15/2019. C2 was released from the hospital on 04/16/2019. LPA Holmes reviewed pertinent information from C#2 file and received copies of information regarding C#2.
No deficiencies cited today during visit

An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9098 01/16) were provided to House manager Kevin Marvel whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2019
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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