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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397006143
Report Date: 03/16/2023
Date Signed: 03/16/2023 03:03:30 PM


Document Has Been Signed on 03/16/2023 03:03 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 260
SACRAMENTO, CA 95833



FACILITY NAME:YAI DAVIS RD. COMMUNITY CRISIS HOME (CCH)FACILITY NUMBER:
397006143
ADMINISTRATOR:ERWIN HIGUEROSFACILITY TYPE:
727
ADDRESS:17834 N. DAVIS ROADTELEPHONE:
(916) 288-9776
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY:4CENSUS: DATE:
03/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Alexandria Tupas, Lead RBTTIME COMPLETED:
10:30 AM
NARRATIVE
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On 3/16/2023 Licensing Program Analyst (LPA) Stephanie Lor arrived at the above facility for the purpose of conducting a case management visit related to an incident report dated 3/7/23 regarding medication issue. LPA met with the Lead RBT.

LPA discussed the incident report and gathered further information. LPA interviewed 2 staff during this case management. The incident report and staff confirm the youth missed one medication due to being on a family visit.

Due to the above, the allegation is SUBSTANTIATED, meaning that the allegation is valid because a preponderance of the evidence standard has been met.

Facility will be cited for violations of the California Code of Regulations, Title 22 Division 6, regulation 80075

A copy of this report was provided at the exit interview. Refer to 9099D for Title 22 deficiencies cited.

SUPERVISOR'S NAME: Rosa RodriguezTELEPHONE: (916) 662-1458
LICENSING EVALUATOR NAME: Stephanie LorTELEPHONE: 530-513-4183
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023
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 2


Document Has Been Signed on 03/16/2023 03:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR., STE 260
SACRAMENTO, CA 95833


FACILITY NAME: YAI DAVIS RD. COMMUNITY CRISIS HOME (CCH)
FACILITY NUMBER: 397006143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2023
Section Cited

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(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.

This was not met as evidenced by:
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The facility will provide a plan of how they will prevent this issue from happening in the future. The plan will be emailed to LPA Lor at stephanie.lor@dss.ca.gov by 3/17/23.
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Client was not given a prescribed medication on 3/6/23.
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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: Rosa RodriguezTELEPHONE: (916) 662-1458
LICENSING EVALUATOR NAME: Stephanie LorTELEPHONE: 530-513-4183
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023
LIC809 (FAS) - (06/04)
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