374604501-5-26-2023-08-AS-DNGN-CS82U8-20230526174154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604501
Report Date: 05/26/2023
Date Signed: 05/26/2023 05:42:01 PM

Document Has Been Signed on 05/26/2023 05:42 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:	DEL REY SPRINGS		FACILITY NUMBER:	374604501
ADMINISTRATOR:	GONZALEZ, EDUARDO		FACILITY TYPE:	735
ADDRESS:	1181 PLAZA AMPARADA		TELEPHONE:	(619) 990-8870
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91910
CAPACITY: 4		CENSUS: 4	DATE:	05/26/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	DSP Veronica Gomez-Zavala		TIME COMPLETED:	05:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with DSP Veronica Gomez-Zavala. LPA also spoke briefly with the Licensee, Eduardo Gonzalez, via phone during today’s visit.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 05/22/2023). According to the LIC624: on 05/20/2023, Client #1 (C1) went AWOL (absent without leave) from the facility. [See LIC 811 Confidential Names List for a description of C1.] Facility staff notified police. Later that same morning, C1 was returned to the facility unharmed/uninjured.

During today’s visit, LPA performed a breif facility tour and interviewed C1, verifying that they were indeed unharmed/uninjured. LPA also collected copies of relevant care and medical records on C1 and interviewed pertinent staff.

According to C1’s latest LIC602 Physician’s Report (dated 03/07/2023): C1 was diagnosed with “moderate intellectual disability” and their doctor determined that they were unable to safely leave the facility unassisted. The doctor also wrote that C1 had “no problem” with depression, being able to communicate, and being able to follow instructions

According to the facility’s Absentee Notification Plan: “If a resident…is noted to be AWOL…the surrounding area will be searched to try to locate them….If the client is not located within 1 hour, staff will contact the Administrator or Licensee….If the client is not located within 2 hours, staff will contact the Police Department to report them as missing…”

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

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: DEL REY SPRINGS	FACILITY NUMBER: 374604501
	VISIT DATE: 05/26/2023

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[CONTINUED FROM LIC 809]

Staff interview revealed: On the morning of 05/20/2023 around 6:05 AM, C1 told Staff #1 (S1) that they wished to go store to buy something. S1 was the only staff on duty at that time. S1 reassured C1 that they would accommodate this shopping request after they finished passing medications and serving breakfast. Around 6:28 AM, C1 left the facility on foot. S1 saw C1 leave but was not able to redirect them, and not to follow them on foot (since S1 needed to remain at the facility to supervise the other three clients in care). S1 immediately notified the licensee via phone. Around the 30 minutes after C1's exit, S1 first phoned local law enforcement for assistance. S1 timely notified C1's responsible party and San Diego Regional Center (SCRC) about the incident.

There does not exist a preponderance of evidence to show that facility staff did not provide needed observation of C1, or that facility staff did not try to mitigate C1's AWOL, or that facility staff did not follow the facility’s Absentee Notification Plan. No deficiencies were cited for the above incident, and no deficiencies were observed during today’s site visit.

LPA provided Technical Assistance regarding the timelines contained in the facility’s Absentee Notification Plan.

An exit interview was conducted with Gomez-Zavala, to whom a copy of this report, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC809 (FAS) - (06/04)

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