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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604330
Report Date: 10/14/2022
Date Signed: 10/14/2022 02:12:24 PM

Document Has Been Signed on 10/14/2022 02:12 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:
10/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Rukhsana Gasque, Licensee and Joseph Baker, Assistant Program DirectorTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit to follow up on two incident reports received by Community Care Licensing on 9/1/22 and 10/4/22. LPA met with Rukhsana Gasque, Licensee and discussed the purpose of the visit.

On 9/1/22, Licensee self- reported an incident that occurred on 8/29/22 regarding Client 1 (C1) and Client (C2) engaging in an argument with each other regarding Client 3 (C3). It was reported that during the preparation of afternoon transport of clients to their residence, C1 and C2 were observed arguing in the parking lot are of the facility.

Interviews were conducted with staff and clients. C1 was not available to be interviewed. C2 reported that C1 came rushing at them on the parking lot of the facility with a knife; however, was not able to get close to them due to staff and Client 4 (C4) blocking them. Staff 1 (S1) stated that they observed C1 looking angry and moving toward C2. S1 stated that there was a great distance between C1 and C2 and they remained between them both. C2 was directed to their transportation van by S1 and C1 was directed to their van by Staff 2 (S2). Staff interviewed did not observed C1 with a knife. Client 5 (C5) stated that they observed C1 with a knife. C4 stated that C1 did not have a knife, however they did have a pen that was taken from their backpack.

Per Licensee, the video footage was reviewed, and you were unable to see a knife in the video. LPA was unable to review the video due to internet issues during the time of the visit. Licensee will submit video via email to LPA. This incident requires further investigation and possible follow-up visits.

On 10/4/22, Licensee self- reported an incident that occurred on 10/4/22 at 9:45 am regarding Client 1(C1) and Client 4 (C4).
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SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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: 10/14/2022
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It was reported that C1 slapped C4 across the face twice and walked off. Interviews with staff and C4 revealed that C1 and C4 were in a relationship and C1 became angry with C4. Staff 3 (S3) was standing in the doorway of the facility as C1 was walking away from C4 after slapping them. S3 immediately redirected C1 and C4 requested to contact Law Enforcement. The police reported to the facility and spoke with C1 and C4. C1 was removed from the facility by law enforcement.

Per Licensee, the video footage was reviewed, and provided to law enforcement. LPA was unable to review the video due to internet issues during the time of the visit. Licensee will submit video via email to LPA. This incident requires further investigation and possible follow-up visits.

Licensee and Assistant Program Director had to leave the facility prior to the conclusion of visit. An exit interview was conducted with Staff Minda Majors, to whom a copy of this report, Confidential Names List (LIC 811) and the Licensee/Appeal Rights (LIC 9058 01/16) were given to Staff Minda Majors..
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
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