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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001830
Report Date: 06/16/2023
Date Signed: 06/16/2023 04:24:55 PM

Document Has Been Signed on 06/16/2023 04:24 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:SV RESIDENTIAL FACILITYFACILITY NUMBER:
397001830
ADMINISTRATOR:VIRGINIA YADAOFACILITY TYPE:
735
ADDRESS:9048 TAM O'SHANTER DRIVETELEPHONE:
(209) 478-9697
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 4DATE:
06/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Virginia YadaoTIME COMPLETED:
04:15 PM
NARRATIVE
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On 6-16-23 at 1:02pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to open a case management regarding an incident which occurred on 5/22/23. LPA met with Administrator Virginia Yadao and explained the purpose of the visit. LPA interviewed Administrator and reviewed incident report dated 5-23-23 as well as individualized program plan (IPP) for resident1 (R1) and Physician's Report (LIC 602) for R1. . Based on interview and record review it was determined that R1 exited facility on 5-22-23 at some time after his return from day program. Interview conducted revealed R1 returned from day program at approximately 2:45pm on 5-22-23. At approximately 4:30pm Administrator learned that R1 was not at the facility after receiving a call from R1's day program that R1 was seen walking down a nearby street alone and picked up by day program due to safety concerns. Administrator then arrived at day program location at approximately 4:40pm to transport R1 back to facility.

R1's IPP dated 3/4/22 and reviewed by LPA revealed R1 is unable to monitor R1's medical and dental needs independently. IPP further states concerns about R1's safety awareness while out in the community. Interview with Administrator revealed facility's internal plan includes providing staff supervision for R1 and all other residents in care due to known safety concerns including absence without supervision (AWOL). Additionally, it was revealed through interview that R1 did not sign out of facility which resulted in an absence of supervision of R1 and facility staff unaware of R1's general whereabouts.

Based on today's case management, a citation is issued under Title 22, Division 6. An immediate civil penalty in the amount of $500 is issued in addition to citation due to absence of supervision. An exit interview was conducted with Virginia Yadao and a copy of this report was provided to Virginia. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
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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Document Has Been Signed on 06/16/2023 04:24 PM - It Cannot Be Edited


Created By: Michael Bilger On 06/16/2023 at 02:59 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: SV RESIDENTIAL FACILITY
FACILITY NUMBER: 397001830

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/19/2023
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee will submit a written plan outlining procedures for maintaining staffs' knowledge of residents' general whereabouts. Plan to be submitted to LPA by POC due date.

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Based on interview and record review, it was determined R1 exited facility on 5-22-23 and facility staff was unaware of R1's general whereabouts resulting in an absence of supervision. This posed an immediate health and safety risk to residents in care.
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Licensee will read regulation 80078(a) and submit a signed declaration of understanding to LPA by POC due date.

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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: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
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