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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005738
Report Date: 12/06/2023
Date Signed: 12/06/2023 10:42:43 AM

Document Has Been Signed on 12/06/2023 10:42 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
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: 3DATE:
12/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:William Puckett - Licensee and Carrie Mumphrey - Assistant AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced case management visit regarding a reported incident from 11.21.23. LPA met with Assistant Administrator and explained the purpose of the visit. Administrator William Puckett was made aware of LPA's visit and purpose. Licensee arrived shortly after LPA was at facility. LPA reviewed incident report with Assistant Administrator and conducted interview with Assistant Administrator. Based on record review and interviews conducted, it was determined that on 11.21.23 at approximately 2:00 am, resident (R1) came downstairs and expressed to staff that R1 wanted to leave facility and buy cigarettes. According to incident report, R1 was followed by two staff until R1 ran out of sight. Staff contacted Stockton Police Department (PD) to report R1 as absent without official leave (AWOL). PD contacted administrator at approximately 2:45 am and stated R1 was safe. R1 requested to be taken to St. Joseph's and didn't want to return to facility. A medical hold was implemented until approximately 6:15 PM on 11.22.23.

An incident report was received by licensing department on 11.21.23. Based on record review, facility has updated R1's file to reflect event described above and R1's continual behaviors. Based on interview, it was determined that report was sent to Valley Mountain Regional Center (VMRC). VMRC is having meeting on today's date with behavior consultant, service coordinator, and licensee.

As a result of today's case management incident visit. A deficiency was cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code. A civil penalty in the amount of $500 is issued as a result of A citation for lack of care and supervision.

An exit interview was conducted with Licensee and assistant administrator. Licensee refuses to sign LIC 809, LIC 809-D, LIC 421IM Civil Penalty.

A copy of LIC 809, LIC 809-D, LIC 811, LIC 811 (Confidential Names), LIC 421IM, and appeal rights were left with Licensee.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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 12/06/2023 10:42 AM - It Cannot Be Edited


Created By: Ruth Wallace On 12/06/2023 at 10:11 AM
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: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2023
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 agrees to submit updated staffing schedule to reflect new staffing plan, updated assessment plan for client and Valley Mountain Regional Center Meeting Notes 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.
michael.bilger@dss.ca.gov
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Based on LPA interviews and record reviews, R1 eloped from facility on 11.21.23 at 2:00 am and was found by Stockton Police Department at approximately 2:45 am on 11.21.23 This poses an immediate health and safety 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:Stephen Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
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