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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604579
Report Date: 01/02/2024
Date Signed: 01/02/2024 04:22:16 PM

Document Has Been Signed on 01/02/2024 04:22 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HEALING ADULT GROUP CARE INC.FACILITY NUMBER:
374604579
ADMINISTRATOR:SAIF, SALLYFACILITY TYPE:
735
ADDRESS:3919 EL CANTO DR.TELEPHONE:
(248) 307-6966
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 4DATE:
01/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator Sally SaifTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Care Giver Valarie Carrillo. LPA also met with Administrator Sally Saif, who arrived later during the visit.

Today's visit was in response to two (2) LIC624 Incident Reports, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/28/2023). According to the LIC624: on the day of 12/9/2023, Client (C1) left the facility after an aggressive behavior, without permission from staff. C1 returned to facility on 12/13/2023. C1 was not taking any prescribed medication at the time of residency. According to the second LIC624: on the day of 12/14/2023, Client (C1) eloped quickly from the transportation vehicle providing transportation from her Adult Day Program to her residence. [See LIC 811 Confidential Names List for a description of C1.].

During today’s visit, LPA performed a facility tour and welfare check on clients in care. LPA also reviewed pertinent records and interview relevant staff.

The LIC602 Physician’s Report (dated 12/4/2023) was very sparse due to an emergency placement and did not indicate any restrictions. The Admissions Agreement (dated 12/4/2023) was agreed by C1 and indicates client may not leave unassisted.

According to C1’s latest IPP-Individual Program Plan (dated on 3/20/2023), their doctor determined that C1 was able to independently complete all personal care and is very knowledge of surrounding community.

[Continued on 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HEALING ADULT GROUP CARE INC.
FACILITY NUMBER: 374604579
VISIT DATE: 01/02/2024
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[Continued from 809]

Interviews, corroborated by records, showed: After C1 departed on 12/9/2023, Administrator Saif received a phone call on 12/13/2023 from the Regional Center case manager and agreed to the return of C1 to the facility. C1 was unharmed/uninjured from the incident. On 12/14/2023 C1 left the facility pick up vehicle from their day program. C1 went back inside the Day Program and then willing left the Day Program. After notifying Regional Center, Administered Saif discharged C1 from the residential facility.


CCLD concluded: Facility staff provided needed supervision to C1 leading up to the AWOL. Licensee had a written Absentee Notification Plan as part of C1’s record of care, and staff followed this plan.

No deficiencies were cited for the above incident. No deficiencies were observed or cited during today's visit.

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

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024
LIC809 (FAS) - (06/04)
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