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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604330
Report Date: 08/18/2022
Date Signed: 08/18/2022 02:54:11 PM

Document Has Been Signed on 08/18/2022 02:54 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:AMARIS CENTER FOR CHANGEFACILITY NUMBER:
374604330
ADMINISTRATOR:GASQUE, RUKHSANAFACILITY TYPE:
775
ADDRESS:250 E DOUGLAS AVETELEPHONE:
(202) 520-3781
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY: 40CENSUS: 26DATE:
08/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Joseph Baker, Assistant Program Director and Rukhsana Gasque, Licensee TIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit to follow up on incident reports received by Community Care Licensing on 7/25/22, 7/29/22 and 8/17/22. LPA met with Rukhsana Gasque, Licensee and discussed the purpose of the visit.

On 7/25/22, LPA received a self reported incident report from the facility regarding inappropriate interactions between Client 1 (C1) and Client (2). It was reported by Client 3 (C3) that they observed C1 give C2 a kiss on the cheek. Per Licensee, C1 and C2 acknowledged the inappropriate interaction. Staff 1 (S1) was present in the same room with C1 and C2, however did not observe the inappropriate behavior.

On 7/29/22, LPA received a self reported incident report from the facility regarding a client participating in illegal activity at another residence. On 7/27/22, Client 5 (C5) reported the information to Staff (S3). Licensee notified responsible party and all outside agencies.

On 7/29/22, LPA received a self reported incident report from the facility regarding client on client assault. On 7/28/22, it was reported during the transporting of clients, Client 2 (C2) took a cell phone from Client 3 (C3). Client 4 (C4) became upset and and asked C2 to return C3's cell phone. C2 became upset and slapped C4 on the hand. Staff 2 (S2) intervened and the cell phone was returned to C3. C2 and C4 were separated on the van. There were no injuries sustained.

On 8/17/22, Licensee submitted a self reported incident report from the facility not received by LPA prior to today's visit. On 8/10/22, Client 6 (C6) reported to Licensee and staff at the facility that they were assaulted by staff at their primary residence. Per licensee and staff, C6 sustained bruises to their back. LPA's observation of documentation reviewed verified that C6 sustained bruising to their back and elbow. Licensee notified responsible party and all required outside agencies. LPA will follow up with the primary facility where C6 resides. Continued on next page
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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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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: AMARIS CENTER FOR CHANGE
FACILITY NUMBER: 374604330
VISIT DATE: 08/18/2022
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During today's visit, LPA Williamson conducted interviews with facility staff and reviewed client records.

No deficiencies were issued during today's visit. An exit interview was conducted with Rukhsana Gasque, Licensee, 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 Licensee.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC809 (FAS) - (06/04)
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