<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700719
Report Date: 06/14/2023
Date Signed: 06/14/2023 04:11:18 PM

Document Has Been Signed on 06/14/2023 04:11 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:OPENDOOR SERVICESFACILITY NUMBER:
392700719
ADMINISTRATOR:NAKAWATASE, JOHNFACILITY TYPE:
775
ADDRESS:1129 ENTERPRISE STTELEPHONE:
(209) 475-1529
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 165CENSUS: 100DATE:
06/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Sherry Welker-LozaTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 6-14-23 at 2:05pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding incidents which occurred on 5-16-23. LPA met with Program Director (PD) Sherry Welker-Loza and explained the purpose of visit. LPA reviewed incident reports dated 5-16-23 and reviewed client records for Resident1 (R1) and R2 as well as Individualized Program Plan (IPP) for resident1 (R1).

Incident #1: On 5-16-23 at approximately 11:14am, R1 eloped from the day program and walked down a nearby street. Based on record review and interview, although staff attempted to follow R1,staff was unable to supervise R1 and was unaware of whereabouts leading to an absence of supervision. Day program notified house manager for R1's facility address as well as police and licensing department. R1 was located at approximately 2:19pm and returned to facility address at approximately 3:02pm. Based on review of R1's physician's report, R1 is unable leave facility unassisted. Additionally, R1's individualized program plan (IPP) states R1 has a history of eloping.

Incident #2: On 5-16-23 according to incident report R2 sustained a fall at approximately 11:28am after experiencing a "seizure like incident (body jerking)". Additionally, incident report stated R2 bumped head on the curb of the sidewalk. Facility staff assessed R2 to determine if R2 was injured and R2 requested to return home. Day program transported R2 back to day program facility and assessed R2 further. At this time, day program staff notice a dime size lump on R2's head and notified R2's facility who arrived at approximately 11:55am to transport R2 back home. Based on interview, R2 returned to program without further incident.

Based on today's case management, citation is issued under Title 22, Division 6. A civil penalty in the amount of $1000 was issued in addition to the citation due to repeat violation within a 12-month period. An exit interview was conducted with Sherry Welker-Loza and a copy of this report was provided to Sherry. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
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
Document Has Been Signed on 06/14/2023 04:11 PM - It Cannot Be Edited


Created By: Michael Bilger On 06/14/2023 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OPENDOOR SERVICES
FACILITY NUMBER: 392700719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/15/2023
Section Cited
CCR
82078(a)

1
2
3
4
5
6
7
Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will submit a plan ensuring staffs' knowledge of resident's whereabouts in the event of elopement episodes. Plan to be submitted to LPA by POC due date.
8
9
10
11
12
13
14
Based on interview and record review, R1 eloped from day program and unsupervised by staff for approximately 3 hours resulting in absence of supervision. This posed an immediate health and safety risk to resident in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2