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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801621
Report Date: 10/12/2023
Date Signed: 10/13/2023 07:35:52 AM

Document Has Been Signed on 10/13/2023 07:35 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:NCI AFFILIATES, INC-LINNEFACILITY NUMBER:
405801621
ADMINISTRATOR:TRACI M HOLLINGERFACILITY TYPE:
775
ADDRESS:496 LINNE ROADTELEPHONE:
(805) 238-6630
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 75CENSUS: 21DATE:
10/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Lote Rouse, Program CoordinatorTIME COMPLETED:
12:24 PM
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 At 10:15am on 10/12/2023, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a Case Management visit regarding the indecent that took place at the facility on 09/27/2023. LPA met with Facility Program Coordinator, Lote Rouse announced who he was and the reason for the visit.
The incident on 09/27/2023, Client 1 (C1) pushed Client 2 (C2) down in the hallway of the facility resulting in injury of C2. Facility self reported incident with Incident report, police report, and staff witness statements. On 10/12/203, LPA conducted interviews of Staff 1 and 2 (S1, and S2). The interview with S1 provided, revealed that C1 stayed back in the classroom during classroom garden time, while C2 requested to use the restroom on the way to the garden, all a typical behaviors of C1, C2 and classroom daily routines. With in seconds to minutes of the classroom stepping outside the hallway door on the way to the garden, C1 pushed C2 to the ground in the hallway. S1 partially observed the incident and recalled seeing C2 falling and C1 rushing to the room number 7 (kitchen).S3 attended to C2 in room 5. S2 and S3 attended to C1 and C2 respectively. Within minuets Facility Program Coordinator arrived and access C2 for injuries, called both parents of C1 and C2 and informed each parent of the incident. C1 was pick up by mother at approximately 2:30pm and has not returned to facility. C2 finished the day at the facility and road the bus home. Additionally, C1 had a planing team meeting on 10/10/2023, and plans to return back to the facility after scheduled a doctors physical. C2 has not returned to the facility as of this date. LPA has reviewed C1 and C2's Individual Personal Plan (IPP), Physicians report and did not observe and special conditions, regarding C1 and C2 about supervision. C1 and C2 are both able to use restroom on their own. Program Coordinator indicated that the Paso Robles Police (PRPD) report (#23-3163) has not resulted in any findings that they know of at this time. LPA will request police report from PRPD in follow up on this incident with Tri- Counties Regional Center, local Quality Assurance Coordinators.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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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