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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700640
Report Date: 10/08/2021
Date Signed: 10/08/2021 01:48:11 PM

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:COURTYARD AT RIO LAS PALMAS, THEFACILITY NUMBER:
392700640
ADMINISTRATOR:GUERRERO, LIZETHFACILITY TYPE:
740
ADDRESS:877 EAST MARCH LANETELEPHONE:
(209) 957-4711
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:80CENSUS: 60DATE:
10/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Lizeth GuerreroTIME COMPLETED:
01:55 PM
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On 10/8/2021 at 11:45am, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a case management visit to follow up on incident report and abuse report submitted to the Department. LPA met with Administrator, explained the purpose of today’s visit, and was was allowed entry into the facility. Current census 60.

LPA received incident report for incident of altercation between Resident one (R1) and Resident two (R2). LPA reviewed records and conducted interviews. Staff one (S1) observed the incident and Staff (S2) and Staff three (S3) responded and assessed R2 for injury, Local Law enforcement arrived, and Staff four (S4) notified responsible parties and physicians. R2 observed to have injury on right arm brazing, R2 declined hospital treatment, and physician did not request follow up appointment after notification. Based on R1 observed changes in behavior S4 requested updated physician's assessment during today's visit.

LPA conducted a case management inspection to ensure proactive measures were put in place to prevent further incidents. If there is another reoccurrence of the same nature occurs the department will return to determine if the current placement continues to be appropriate.

Per the California Code of Regulations, Title 22, no deficiencies observed or cited. Exit interview held and a copy of report provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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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