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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700539
Report Date: 09/24/2021
Date Signed: 09/24/2021 12:42:38 PM

Document Has Been Signed on 09/24/2021 12:42 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CHAMPION RESIDENTIALFACILITY NUMBER:
392700539
ADMINISTRATOR:BOYD, JAMESHAFACILITY TYPE:
735
ADDRESS:481 SPRING RIVER CIRCLETELEPHONE:
(510) 815-8570
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 4CENSUS: 4DATE:
09/24/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Danielle CarpenterTIME COMPLETED:
12:25 PM
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On 9/24/21 at 10:08am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for an incident report dated 8/16/21 involving Resident1 (R1) sent to hospital. LPA met with Danielle Carpenter and explained the purpose of the visit. Administrator Jamesha Boyd was not present and gave permission for Danielle Carpenter, facility manager to accompany LPA and sign in her absence.

LPA conducted a case management inspection to ensure Title 22 compliance and health and safety concerns. All sharp objects and toxins were secured and inaccessible to clients in care. Room temperature was adequate at 75*F during today’s visit. There are no obstructions to fire exits inside or outside facility. There were 2 staff on duty during visit. According to incident report dated 8-16-21 R1 was sent to the hospital on 8-15-21 after slight bruising was noted on R1s legs by staff. Additionally, according to incident report, while R1 was in the hospital, R1 made a statement that she was assaulted by a male staff.

LPA reviewed R1s Individualized Program Plan (IPP), Individual Service Plan (ISP) physician’s report, facility care notes, and incident report dated 8-16-21. LPA interviewed R1 at 10:35am, Staff1 (S1) at 11:15am and S2 at 12:05pm. Based on the interviews conducted and records reviewed it was revealed that R1’s allegation of being assaulted was a falsified statement. Based on interview with R1 on 9-24-21, it was quoted by R1 that the reported incident of R1 being assaulted was “not true.” Additional record review of IPP indicated that R1 has a history of falsified statements and hallucinations.

{Cont on 809C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CHAMPION RESIDENTIAL
FACILITY NUMBER: 392700539
VISIT DATE: 09/24/2021
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 IPP and ISP review reveals that a behavior intervention plan is in place to address history of false accusations and other behaviors. Review of staffing roster revealed that there are no male staff members who work with R1.
Based on the interviews, inspection, and documentation reviewed, the department has closed this case management and no further investigation is required.

Per California Code of Regulations, Title 22 there were no deficiencies observed or cited during today's case management inspection.

An exit interview was conducted with Danielle Carpenter and a copy of this report was left with Danielle.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
LIC809 (FAS) - (06/04)
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