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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604330
Report Date: 09/29/2022
Date Signed: 09/29/2022 12:56:14 PM

Document Has Been Signed on 09/29/2022 12:56 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: 28DATE:
09/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Rukhsana Gasque, LicenseeTIME COMPLETED:
01:10 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 9/20/22. LPA was granted entry into the facility by Joseph Baker, Assistant Program Director. LPA then met with Rukhsana Gasque, Licensee, to whom she discussed the purpose of the visit.

The incident reported the absence without leave (AWOL) of Client 1 (C1) (See LIC 811 Confidential Names to identify C1) that occurred on 9/13/22. C1 was last seen at the facility on 9/13/22, at 12:20pm. Per licensee, C1 asked to leave program at 12:30 pm to pick up a family member. C1 was advised that the program would be over at 1:30pm and that they had not obtained prior approval. C1 left the facility at 12:30pm. C1 is independent and able to access the community; however their outings during program hours are approved by an outside agency. C1 transports to and from facility by bus.

Licensee Ruskhana Gasque, stated that the police department was not contact due to C1 is independent. Licensee immediately contacted an outside source who authorizes C1’s outings.

A records reviewed determined that C1 is independent and lives on their own, they use the bus to transport to and from day program daily.

LPA was conducting another visit at the facility on today (9/29/22) and observed Client 2 (C2) (See LIC 811 Confidential Names to identify C2) walk out of the facility parking lot and onto the sidewalk in front of the facility. Staff 1 immediately ran to the end of the parking lot to the sidewalk area and joined C2 in his walk. Staff 1 and C2 returned C2 to the facility together after walking the block. C2 advised LPA that they were upset and wanted to go home.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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: 09/29/2022
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A records reviewed determined that C2 is not allowed off the premises without supervision. Licensee contacted C2’s responsible party and they reported to the facility to pick up C2. LPA and C2's responsible party discussed client's Personal Rights.

During today's visit, LPA Williamson interviewed Joseph Baker, Assistant Program Director, Rukhsana Gasque, Licensee, a client, responsible party and reviewed records for C1 and C2.

Licensee will submit an Unusual Incident Report to Community Care Licensing.

No deficiencies were issued during today's visit. An exit interview was conducted with Rukhsana Gasque, Licensee, to whom a copy of this report and the Licensee's/Appeal Rights (LIC9058 01/16) were provided to Licensee.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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