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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850543
Report Date: 08/02/2024
Date Signed: 08/02/2024 08:46:06 AM

Document Has Been Signed on 08/02/2024 08:46 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:YOUNG ADULT FAMILY HOMEFACILITY NUMBER:
405850543
ADMINISTRATOR/
DIRECTOR:		YOUNG, DIANEFACILITY TYPE:
735
ADDRESS:1949 L STREETTELEPHONE:
(805) 423-8902
CITY:SAN MIGUELSTATE: CAZIP CODE:
93451
CAPACITY: 4CENSUS: 4DATE:
08/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Licnesee, Diane YoungTIME VISIT/
INSPECTION COMPLETED:
11:06 AM
NARRATIVE
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 At 8:00am on 07/29/2024, Licensing Program Analyst (LPA) Jeffries and Tri Counties Regional Center (TCRC), Quality Assurance Specialist(QA) Briana Hertwell arrived at the facility unannounced to conduct a case management visit based on incident reports by the facility which were submitted to TCRC for incident that took place on 06/12/2024. LPA met with Licensee, Diana Young announced who they are and the reason for the visit.
Two TCRC incident reports dated 06/02/2024 and 07/01/2024 indicated Clients in care were witness to "altercation between the Young Family" or "dispute" as reported in incident reports descriptions singed by Licensee Diane Young. LPA Jeffries notes that the Administrator Dolly Schwed or Licensee Diane Young failed to notify Community Care Licensing (CCL)of the incident on 06/12/2024. LPA also noted that facility under license number 405850283, on 04/04/2024, had a substantiated complaint of the allegation of, “Clients are not living in a safe or healthful environment.” As a result of staff confrontations in the presence of clients. The Plan of Corrections for that substantiated allegation was a personal rights training that was submitted by email to LPA on 04/22/2024 which shows Administrator, Staff 1-3 (S1, S2, and S3) completed that training on 04/19/2024. Despite the training, on 06/12/2024 staff who participated in that training engaged in an “altercation and/or dispute” in the presence of clients as indicated on the two incident reports submitted to TCRC. This is the second time, in period of less than 12 months that a violation of client’s personal rights was reported, which threatens the emotional safety of clients in care, which has been documented. A citation and civil penalty are assessed for the repeat violation, and a citation is issued for the failure to report incident to Community Care Licensing is also cited.
QA and LPA also address question and photographs clients rooms.

Exit interview, citations and civil penalty issued, report and appeal rights provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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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Document Has Been Signed on 08/02/2024 08:46 AM - It Cannot Be Edited


Created By: Mark Jeffries On 07/28/2024 at 04:55 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: YOUNG ADULT FAMILY HOME
FACILITY NUMBER: 405850543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2024
Section Cited
CCR
80072(a)(1)

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80072 Personal Rights (a)…, each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met by evidence of two incident reports
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Administrator agrees to all staff to participate in Clients Personal Rights Training authorized and provided through TCRC vendor. To be scheduled and proof provided to LPA on or before 08/16/2024. (mark.jeffries@dss.ca.gov)
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submitted to TCRC pertaining to altercation/dispute in presence of clients in care. Which poses a potential danger to clients in care.
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Type B
08/13/2024
Section Cited
CCR80061(b)(1)(E)

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80061 Reporting Requirements (b) Upon the occurrence…a written report … shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following. (E) Any unusual incident… which threatens
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Administrator agrees to all staff to participate in Reporting Requirements as authorized and provided through TCRC vendor. To be scheduled and proof provided to LPA on or before 08/16/2024.
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 the physical or emotional health or safety of any client. This requirement was not met by evidence of failure to submit SIR of 06/12/2024 incident to CCL. Which poses a potential risk to clients 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:Mark Jeffries
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024


LIC809 (FAS) - (06/04)
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