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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700298
Report Date: 06/13/2023
Date Signed: 06/13/2023 03:11:43 PM

Document Has Been Signed on 06/13/2023 03:11 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DIZON VALLEY CARE HOMEFACILITY NUMBER:
392700298
ADMINISTRATOR:DIZON, LISSETFACILITY TYPE:
735
ADDRESS:2830 SAN ROCCO DRTELEPHONE:
(510) 435-7428
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 6CENSUS: 5DATE:
06/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mary BaldwinTIME COMPLETED:
12:00 PM
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On 06/13/2023 at 11:00am, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to conduct a case management visit. LPA was greeted by staff member (SM), Margaret Prock and explained the purpose of the visit. It was at this time where the LPA asked that SM Prock to call the Facility Designated Administrator (FDA), Lissett Dizon to notify her that CCL was present at this time. LPA Pascua was able to speak to FDA Dizon on the phone and was notified that the LPA will meet with Facility Designated Representative (FDR), Mary Baldwin.

Shortly after, LPA met with FDR Baldwin. The purpose of this case management visit was to follow up on an incident that was received by the department on 06/12/2023. It was stated on the incident that on 06/10/2023 staff noticed that R1's door was open. It was learned that R1 left the facility and walked across the street to the neighbors yard. R1 was taken back to the facility shortly after. On 06/13/2023 around 6:00am, R1 eloped from the facility a second time and was taken back to the facility after Tracy Police and staff found them at a nearby park.

LPA obtained R1's physicians report and learned that R1 is allowed out of the facility without assistance. The facility has also contacted R1's service coordinator and behaviorist to help with different interventions to mitigate any elopements in the future.

Based on interview and records review there were no deficiencies that were cited during this case management visit. LPA Pascua will come at a later time if further follow up is needed.
A copy of this report was provided to the facility and an exit interview was conducted.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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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