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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604148
Report Date: 01/09/2024
Date Signed: 01/09/2024 03:28:59 PM

Document Has Been Signed on 01/09/2024 03:28 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:ABIGAIL'S HOMES IIFACILITY NUMBER:
374604148
ADMINISTRATOR:GONZALEZ, BRENDA ABIGAILFACILITY TYPE:
735
ADDRESS:8738 VALENCIA STTELEPHONE:
(619) 315-7407
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 3DATE:
01/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Caregiver Dario GonzalezTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to issue a deficiency identified during an unrelated complaint investigation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Dario Gonzalez. LPA spoke to Administrator Brenda Gonzalez via phone.

During a complaint investigation, the Department interviewed clients, staff, and outside sources, reviewed facility records, and conducted a tour of the facility. During the investigation, it was determined that Client 1 (C1) was considered a fall risk. [LPA provided Dario with an LIC811 Confidential Names list to identify C1] Review of C1’s physician’s report dated January 2020 revealed that C1’s physician report was not updated to reflect C1’s fall risk diagnosis. Review of C1’s assessment records and interviews with facility staff and management revealed that C1’s records had not been updated to show that C1 was a fall risk, but facility staff had been verbally informed that C1 was a fall risk by the Administrator. Although C1’s physician had deemed C1 as a fall risk, C1’s physician report and appraisal documents had not been updated to reflect C1’s change in condition.

The following deficiency is cited per California Code of Regulations, Title 22 and noted on the attached LIC809-D page.

An exit interview was conducted with Administrator Brenda Gonzalez via phone and Caregiver Dario Gonzalez, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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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Document Has Been Signed on 01/09/2024 03:28 PM - It Cannot Be Edited


Created By: Rebecca A Ruiz On 01/09/2024 at 02:30 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ABIGAIL'S HOMES II
FACILITY NUMBER: 374604148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2024
Section Cited
HSC
80068.3(a)

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80068.3 Modifications to Needs and Services Plan (a) The licensee shall ensure that each client’s written Needs and Services Plan is updated as often as necessary to assure its accurate… This requirement has not been met as evidenced by:
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Administrator will contact Regional Center for an updated assessment to add standby supervision while showering and fall risk to C1's care plan and physician's report. Administrator will submit a copy of C1's updated LIC602 to the Department by POC due date of 2/6/2024.
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Based on interviews and records review, the licensee did not ensure that 1 of 4 clients (C1’s) physician’s report was updated to show C1’s fall risk determination. This posed a potential health and safety risk to C1.
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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:Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
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