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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701106
Report Date: 02/17/2023
Date Signed: 02/17/2023 12:13:49 PM

Document Has Been Signed on 02/17/2023 12:13 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:LA FAMILIA RESIDENCE 2 INC.FACILITY NUMBER:
392701106
ADMINISTRATOR:YEPIZ, GUADALUPE CRYSTALFACILITY TYPE:
735
ADDRESS:570 SANDPIPER CIRTELEPHONE:
(209) 331-9417
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 6CENSUS: 4DATE:
02/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Lupita YepizTIME COMPLETED:
12:30 PM
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On 2/17/23 Licensing Program Analyst Maja Jensen arrived at facility to conduct a case management regarding an incident report and pending eviction for Resident 1 (R1). LPA Jensen met with Licensee Lupita Yepiz and explained the purpose of today's visit.

LPA Jensen interviewed Licensee Yepiz who advised that staff has observed an increase self injurious behaviors when R1 is in communication family member 1 (F1). LPA Jensen reviewed the resident file for R1 and notes that all reportable incidents have been documented and reported to the department and any other agencies as appropriate in a timely manner. The Licensee advised that meetings are held every other week to discuss all concerns and resident needs. The Licensee advised that the regional center is exploring options including conservatorship. LPA Jensen reviewed R1's.

R1 keeps a journal of feelings and actions. LPA Jensen reviewed R1's journal and determined it substantiates staff concerns.

No citations are being issued as a result of this case management.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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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