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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800830
Report Date: 07/11/2023
Date Signed: 07/11/2023 04:03:27 PM

Document Has Been Signed on 07/11/2023 04:03 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AMERICAN CARE HOMEFACILITY NUMBER:
405800830
ADMINISTRATOR:LIXIA ZHANGFACILITY TYPE:
735
ADDRESS:1240 EL CAMINO REALTELEPHONE:
(805) 466-9029
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 38CENSUS: 30DATE:
07/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Lixia Zhang, LicenseeTIME COMPLETED:
04:15 PM
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On 7/11/23 at 2:22 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced Case Management-Incident visit to the facility listed above to investigate an incident reported by the facility. LPA met with Lisa Zhang, Licensee, and explained the purpose of the visit.

On 6/26/23, CCL received an Incident Report from the facility stating that Resident #1 (R1) contacted police on 6/23/23 and reported that they had been assaulted by Staff #1 (S1). The Report states that the police found no evidence of assault. LPA interviewed the licensee, staff, and residents. Licensee says she was not present at the time of the incident and says that R1 “says things like this sometimes and he used to hit people.” She says R1 did not bring the concern to staff before calling the police, and staff learned of the incident when police arrived. She says R1 typically brings concerns to her.

LPA interviewed the Administrator. Administrator says that R1called the police on 6/23/23, the police came to the facility and investigated, but did not find evidence that the assault happened. She says R1 told her of the incident saying that R1 received scratches from the assailant, however, when she asked to see the scratches, R1 would not show them to her. Administrator says there have been no prior conflicts between S1 and R1.

LPA interviewed residents. One resident says that they were here when the police showed up “about a month ago” and R1 told this resident that S1 assaulted R1. Resident says that “R1 has a history of making up stories like this and R1 has alleged that three other people have assaulted R1 in the past.” Resident says they don’t believe R1 because they didn’t see any scratches on R1 and “R1 has made self-inflicted injuries in the past.” Residents say that staff are good to them.

Based on the evidence obtained, there is no evidence that S1 assaulted R1. No deficiencies cited at this time.

Exit interview conducted, report given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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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