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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005738
Report Date: 07/13/2022
Date Signed: 07/13/2022 03:08:14 PM

Document Has Been Signed on 07/13/2022 03:08 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:INSPIRING CAREFACILITY NUMBER:
397005738
ADMINISTRATOR:PUCKETT, VICTORIAFACILITY TYPE:
735
ADDRESS:2488 NATHANIEL STREETTELEPHONE:
(209) 951-2405
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 5CENSUS: 4DATE:
07/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Carrie MumphreyTIME COMPLETED:
01:50 PM
NARRATIVE
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On 7-13-22 at 10:30am, Licensing Program Analysts (LPAs) Michael Bilger and Renee Campbell arrived unannounced to conduct a case management visit regarding an incident reported on 6-24-22. LPA met with assistant administrator Carrie Mumphrey and explained the purpose of the visit. LPA Bilger spoke with Administrator William Puckett and explained the purpose of the visit. LPAs interviewed Administrator, assistant administrator, and resident1 (R1). LPAs also reviewed incident report dated 6-24-22 and hospital notes for R1.

Based on interviews and record reviews it was determined that R1 exited facility on 6-24-22 at approximately 2:00am. It was further determined that 1 staff member was on duty during the elopement episode, and additional staff arrived to attempt locate R1, but were unsuccessful in determining R1s whereabouts until 6:00pm when police department returned R1 to facility. Upon further interviews, it was determined that R1 stated she was inappropriately touched by an individual outside of the facility during R1's elopement period. Interview with assistant administrator and Administrator concluded that after learning of alleged abuse, police department was notified, but notification to licensing department and ombudsman was not completed

As a result of today's visit, deficiencies are cited under Title 22, Division 6. An exit interview was conducted with Carrie Mumphrey and a copy of this report was left with Carrie. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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 07/13/2022 03:08 PM - It Cannot Be Edited


Created By: Michael Bilger On 07/13/2022 at 01:36 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: INSPIRING CARE
FACILITY NUMBER: 397005738

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/14/2022
Section Cited
CCR
80078(a)

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80078(a) Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:
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Licensee agreed to add additional staff member on night shift to aid in care and supervision of elopement risk residents. Licensee to submit updated staffing schedule to reflect new staffing plan to LPA by POC due date.

Licensee will read regulation 80078(a) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interviews and record reviews, R1 eloped from facility on 6-24-22 at 2:00am and faclity staff was unaware of R1's whereabouts until 6:00pm on 6-24-22. This poses an immediate health and safety risk to residents in care.
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Type B
07/22/2022
Section Cited
CCR80061(d)

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(d) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1)
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Licensee will read regulation 80061(d) and submit a signed declaration of understanding to LPA by POC due date.

Licensee will complete reporting requirements as specified by regulation 80061(d) and submit proof of reporting to LPA by POC due date.
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This requirement is not met as evidenced by:

Based on interviews and record reviews, it was determined that R1 alleged inappropriate touching by an outside individual during an elopement period on 6-24-22 which was not reported to licensing department or ombudsman. This poses a potential health, safety, and resident rights risk to residents in care
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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: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022


LIC809 (FAS) - (06/04)
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