<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
397001415
Report Date:
12/20/2024
Date Signed:
12/20/2024 11:35:47 AM
Document Has Been Signed on
12/20/2024 11:35 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
UCP OF SAN JOAQUIN.CALAVERAS AND AMADOR
FACILITY NUMBER:
397001415
ADMINISTRATOR/
DIRECTOR:
TONISHA MIXON
FACILITY TYPE:
775
ADDRESS:
7616 PACIFIC AVENUE #A6
TELEPHONE:
(209) 956-0290
CITY:
STOCKTON
STATE:
CA
ZIP CODE:
95207
CAPACITY:
87
CENSUS:
34
DATE:
12/20/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:13 AM
MET WITH:
Jane Johnson
TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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
LPA Johnson arrived unannounced and met with Jane to conduct a case management visit. The purpose of this visit is in response to an unusual incident report that was received by CCL regarding physical abuse of a resident in care.
It was reported that a female staff (S1) struck a resident with an open hand on the back of the head with enough force to push the residents head forward. R1 was visibly upset by the incident. R1 has some identified behavior challenges including in his individual program plan they are listed as grabbing and bitting. The incident did not require medical attention or any form of first aid. The incident was witnessed by S2.
S2 provided a written statement detailing the event.
LPA reviewed the staff and resident files. S1 does not have any past history of inappropriate relations with residents or any history of disciplinary action while an employee of the program. An investigation of the incident was conducted by the program which resulted in S1 being terminated for her actions. It was also noted during the investigation that this program is not a behavior intervention program that would require training to identify and response to maladaptive behaviors that R1 has been displaying while at the program.
No deficiencies are being cited during today's visit. (Advisories given)
Exit interview conducted and a copy of this report was left at the program.
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Albert Johnson
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/20/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/20/2024
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
1