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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700461
Report Date: 06/06/2022
Date Signed: 06/06/2022 03:29:02 PM

Document Has Been Signed on 06/06/2022 03:29 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:KIRSTEN COURT CARE HOMEFACILITY NUMBER:
392700461
ADMINISTRATOR:QURESHI, MUHAMMADFACILITY TYPE:
735
ADDRESS:2553 KIRSTEN COURTTELEPHONE:
(209) 224-1946
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 4CENSUS: 4DATE:
06/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Mariah Green, Direct Support StaffTIME COMPLETED:
03:45 PM
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On 06/06/2022, Licensing Program Analyst (LPA) T. White conducted case management visit regarding incident submitted to CCLD on 05/12/2022. LPA spoke with Administrator, Muhammed "Ali" Qureshi and explained the purpose of the visit.

Based on incident report, Client #1 (C1) was discharged from Lodi Memorial with a diagnosis of suicidal behavior with attempted self injury and suicidal ideation. C1 was picked up by staff and is currently at home now. Based on incident report, Administrator and client followed up with client's psychiatrist on 05/12/2022 for increase in psychiatric medications.

Based on interview with Staff #1 (S1), C1 attempted to cut her arm with a thumbtack. S1 stated staff called the police regarding incident. The police asked C1 if she wanted to kill herself. C1 stated "yes" and tried to attack police officers. C1 was then handcuffed and taken to the hospital. The facility attempted to have a meeting with Regional Center regarding incident. S1 stated meeting was cancelled on 05/31/2022. S1 agreed to come up with a written plan regarding incident.

S1 stated C1's medication was increased and no suicidal ideation has not been noted since that incident.

No deficiencies cited during inspection.

Exit interview conducted with Administrator and a copy of report given.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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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