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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801561
Report Date: 04/12/2023
Date Signed: 04/12/2023 03:34:48 PM

Document Has Been Signed on 04/12/2023 03:34 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:TRAFFIC WAY HOUSEFACILITY NUMBER:
405801561
ADMINISTRATOR:DEBBIE STARLINGFACILITY TYPE:
735
ADDRESS:5000 TRAFFIC WAYTELEPHONE:
(805) 466-0721
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 14CENSUS: DATE:
04/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Debbie Starling, Licensee/AdministratorTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Chavez conducted an unannounced case management - deficiencies visit to issue deficiencies discovered during complaint investigation 29-AS-20221005122220. During today’s visit, LPA met with Debbie Starling, Licensee/Administrator, and explained the reason for the visit. Also, in attendance was Miguel Magana, Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS).

It was discovered during the investigation that although Client #2 (C2) had several incidents regarding inappropriate sexual behaviors, facility staff did not reassess C2 or update their needs and services plan to include additional supervision. The lack of supervision contributed to C2 sexually assaulting Client #1 (C1).

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).

Exit interview conducted, deficiency cited, and the report and appeal rights given to the licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2023
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 04/12/2023 03:34 PM - It Cannot Be Edited


Created By: Darlene Chavez On 04/12/2023 at 02:01 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRAFFIC WAY HOUSE
FACILITY NUMBER: 405801561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2023
Section Cited
CCR
80068.2(b)(2)

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80068.2(b)(2) Needs and Services Plan
(b)(2) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency… the Department may consider the plan to meet the requirements of this section provided that: The licensee and the placement agency agree that the client's physical, mental and emotional status has not significantly changed since the assessment. This requirement was not met as evidenced by:
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Licensee will conduct an updated Needs and Service Plan for C2 and send to CCL by 4/19/23.
Licensee has started C2 in the TCRC Get Safe program (counseling), C2’s medication has changed, and C2 starts monthly psychiatric evaluations on 4/19/23. Licensee will provide outcomes from psych evals to CCL by 4/20/23.
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Based on interviews and record review, the licensee failed to ensure proper supervision of residents in care resulting in C2 sexually assaulting C1, which posed a potential health, safety, and personal 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:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023


LIC809 (FAS) - (06/04)
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