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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603933
Report Date: 09/28/2022
Date Signed: 09/28/2022 03:44:12 PM

Document Has Been Signed on 09/28/2022 03:44 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:SPEARMAN LANE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
374603933
ADMINISTRATOR:YADIRA WALKERFACILITY TYPE:
735
ADDRESS:2269 POINTE PARKWAYTELEPHONE:
(619) 368-0626
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91978
CAPACITY: 6CENSUS: 5DATE:
09/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Ethel Gray, House ManagerTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit to follow up on an incident report received by Community Care Licensing on 8/19/22. LPA met with Ethel Gray, House Manager and discussed the purpose of the visit.

On 8/19/22, LPA received a self- reported incident report from the facility regarding a client sustaining an unexplained injury to the right hand. On 8/18/22, during the evening hours Client 1 (C1) was observed by Staff 1 (S1) to have swelling on right forefinger and thumb. Staff did not observe any accident that could have caused the injury. C1 is non verbal and unable to verbally express pain, however showed no restrictions in their regular movement.

Per Ms. Gray she was contacted by S1 regarding his observation of the swelling to C1's finger and thumb on the right hand. Ms. Gray observed the injury and C1 was provided medical attention by a physician and diagnosed with a hairline fracture.

During today's visit, LPA Williamson briefly toured the facility, conducted interviews with facility staff and reviewed client records. A review of records revealed that C1 has self injurious behaviors and often causes injury to himself.

No deficiencies were issued during today's visit. An exit interview was conducted with Ethel Gray, House Manager, to whom a copy of this report, Confidential Names (LIC 811) and the Licensee's/Appeal Rights (LIC 9058 01/16) were provided to the House Manager.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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