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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802304
Report Date: 03/25/2024
Date Signed: 03/25/2024 12:28:36 PM


Document Has Been Signed on 03/25/2024 12:28 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:A HEAVENLY COMMUNITIES AFACILITY NUMBER:
405802304
ADMINISTRATOR:JIMENEZ, JENNIFERFACILITY TYPE:
740
ADDRESS:2025 UNION ROADTELEPHONE:
(805) 296-3239
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 5DATE:
03/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Licensee?Administrator Jennifer JimenezTIME COMPLETED:
01:03 PM
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At 10:30am on 03/25/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct an case management visit for the incident: Elopement with injury on 03/20/2024. LPA noted that the facility had contacted LPA by phone 03/21/2024 of elopement from facility where resident sustained a fractured nose when they left facility during the evening of 03/20/2024 around 8:15pm. Facility noticed resident (R1), missing at approximately 10:00pm on 03/20/2024. Facility notified licensees/administrators and local Paso Robles Police Department (PRPD) at 10:52pm. Upon call to 911 it was learned that R1 was discovered by PRPD with a fractured nose. Incident report was submitted 03/22/2024 which added R1 was fond on "floor" and was taken to ER and treated for a cut above eye, requiring 4 stiches, and fractured nose. Incident report indicated that R1 squeezed through facility driveway gate.

LPA interviewed staff, conducted a facility tour, reviewed and collected documents, and took photographs. Staff interviews indicated that R1 was assisted to their bedroom at approximate 7:45pm. At approximately 8:00pm R2 was assisted to their bedroom by Staff (S1). At approximately 9:00pm S1 called for assistance from MedTech (S2) to assist with R3 with incontinence issues. S1 conducted routine bed checks at 10:20pm and discovered that R1 was not in their bedroom. S1 conducted an imitated search of the facility and facility grounds and discovered that R1 was not present at the facility. S1 contacted 911, Administrator and Licensees. At approximately 11:00pm the two licensees, S2, and 3 administrators from the other on campus facility's conducted a perimeter search inside and outside the facility area. PRPD dispatcher informed Licensee that R1 was already found at 9:54pm and was being transported to Sierra Vista Hospital where they were treated for the injuries described above. R1 returned to the facility later that evening.

LPA interview Licensee's and Administrator who concurred the events described above. Licensee stated that they are going to implement the follow precautions are a result of the elopement.
CONTINUED on LIC812



SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2024
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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