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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604330
Report Date: 10/03/2022
Date Signed: 10/03/2022 01:57:02 PM

Document Has Been Signed on 10/03/2022 01:57 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: 30DATE:
10/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Joseph Baker, Assistant Program DirectorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vicky Williamson conducted a case management visit to cite for deficiencies in regard to a complaint visit on 10/3/22 and a case management visit on 7/19/22. LPA met withJoseph Baker, Assistant Program Director and discussed the purpose of the visit.

Licensee Rukhsana Gasque did not report the absence without leave (AWOL) to Community Care Licensing for C1 that occurred on 7/11/22. In addition, an AWOL that occurred on 6/21/22, involving C1 was not reported to Community Care Licensing until 7/15/22. License notified the outside sources and responsible party, however did not contact Community Care Licensing.

Records reviewed determined that C1 is not allowed off the premises without supervision.

During today's visit, LPA Williamson discussed reporting requirements, unusual incidents, and additional staffing with Joseph Baker, Assistant Program Director.

The deficiency is noted on the attached LIC 809D and is cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 3.

An exit interview was conducted with to Joseph Baker, Assistant Program Director, to whom a copy of this report and the Licensee's Rights (LIC9058 01/16) were provided licensee.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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Document Has Been Signed on 10/03/2022 01:57 PM - It Cannot Be Edited


Created By: Vicky Williamson On 10/03/2022 at 10:35 AM
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: AMARIS CENTER FOR CHANGE
FACILITY NUMBER: 374604330

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2022
Section Cited
CCR
82061(a)(1)(D)

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Reporting Requirements (a)Upon the occurrence, during the hours the day program is providing services to the client, ..., a report shall be made to the licensing agency within the agency's next working day... In addition, a written report ... shall be submitted to the licensing agency within seven days...
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Assistant Program Director will cmplete a training with an outside source for staff and submit proof of training by POC date.
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(D) Any unusual incident ... the physical or emotional health or safety of any client; The requirement was not met as evidence by: Based on Licensee's own admission, incident report regarding the AWOL of C1 on 7/11/22 was not reported to CCL, incident on 6/21/22, was reported on 7/15/22, more than 7 days.
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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:Simon Jacob
LICENSING EVALUATOR NAME:Vicky Williamson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
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