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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850543
Report Date: 09/12/2024
Date Signed: 09/12/2024 09:40:30 AM

Document Has Been Signed on 09/12/2024 09:40 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:		D0LLY SCHWEDFACILITY TYPE:
735
ADDRESS:1949 L STREETTELEPHONE:
(805) 423-8902
CITY:SAN MIGUELSTATE: CAZIP CODE:
93451
CAPACITY: 4CENSUS: 2DATE:
09/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Licensee, Diane YoungTIME VISIT/
INSPECTION COMPLETED:
10:34 AM
NARRATIVE
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 At 8:00am on 09/12/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a subsequent case management visit, as a result of information from interviews conducted during a complaint investigation (29-AS-20240802140422). A complaint final findings visit for that complaint was also competed during this visit. Additionally, the case management visit addresses findings pertaining to a Serious Incident Report (SIR) from the facility dated 09/08/2024 of Client 3 (C3) missing 7 days of a Physicians prescribed medication (Med 1), and 10 days of Med 2. LPA met with Licensee, Diane Young and announced the reason for the visit.

On 08/15/2024, LPA Jeffries conducted in person interviews with Clients 1 (C1) and 2 (C2) for a subsequent complaint investigation. C1 and C2 were both interviewed individually and separately on 08/15/2024. When LPA asked C1 if they had ever been in trouble at the facility C1 stated that S3 put them in “time-out”. C1 stated that time-out meant sitting on the floor in their room facing the dresser or back of the door. When asked why they thought they were put in time-out? C1 stated that S3 was mad and yelled to them, “Don’t ever touch my kids fucking toys!”. C1 denies S3 ever touching C1 or C2 physically, just yelling and punching the walls. In LPA’s interview with C2, when asked if they have ever been in trouble at the facility, C2 stated “yes” … “time-out”, When C2 was asked, why were they were put in time-out? C2 stated, “S3 was yelling at me.” When asked, why was S3 yelling at you, C2 put head down and did not answer, When C2 was asked, where was time out? C2 replied, “floor, facing dresser” LPA confirmed with C2 that floor in their room at the facility When C2 was asked about S3 touching them S3 stated “No” When asked about S3 hitting the walls of the facility C2 put their head down and declined to answer. On 08/09/2024, LPA conducted an interview with Witness 1 (W1) who stated that the facility had “several holes in the walls, at the closing of the last facility location, when LPA asked how many holes were in the walls, W1 stated “several”. W1 took photographs of holes in the walls of the facility dated once the Licensee vacated the last facility location.

CONTINUED on LIC809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 405850543
VISIT DATE: 09/12/2024
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As a result of these new findings, a citation of Personal Rights violations [80072(a)(1)] will be issued and subsequent civil penalty will be assessed for the third recorded incident of Personal Rights violation within a 12-month period. Prior recorded incidents of Personal Rights violations filed on 04/04/2024, and 08/02/2024.

Additionally, an SIR from the facility was submitted to Community Care Licensing (CCL) on 09/10/2024, which was dated 09/06/2024 for a missed medication of C3. This incident report indicated that on 08/14/2024, C3 took their last filled dose of Medication (Med 1) and had been without Med1 for 7 days from 08/15 -21/2024. Facility SIR also stated that “Conservator handles it all”, pertaining to medical visits, and medications. On 9/11/2024 LPA contacted Licensee Diane Young by phone. Licensee stated that S3 had been out of Med1 for 7 days while in the facility. Licensee stated the Conservator was responsible for all medication and medical appointments. LPA requested Conservators contact information. On 09/11/2024 LPA contacted Conservator by phone. Conservator stated that they are currently helping get Med1 and Med 2 to be issued on the same day and not in the middle of the month but is only helping coordinate that medication date change and has not been responsible for ordering or maintaining the medication for C3. Conservator stated, “I don’t feel like she (Licensee) has communicated effectively when C3 has ran out of medications.” C3 also stated that, Licensee told me that C3 has been working on their behavior and wondered if they needed Med 2”. Conservator also stated during this interview that S3 is currently out of Med 2 and has been out since 09/01/2024 which is 11 days without Med 3 for C3. Conservator stated that they are working with Licensee, only to get the mid-month medication cycles synched up so no medication comes at the middle of the month and that the Licensee has handled all the other medication orders through Coast Pharmacy. Both Licensee and Conservator confirmed that C3 left the facility on 08/31/2024 for a home visit. C3 did not have Med 2 on 09/01/2024 according to Conservator. Based on the date of the SIR submitted by the facility on 09/10/2024, the date that C3 missed their first dose of Med 1 on 08/15/2024 and not reporting to CCL that C3 missed a second medication (Med 2) on 09/01/2024, a citation is issued to the facility for Reporting Requirements [80061(b)(1)(E)] and a civil penalty is assessed for the repeat violation having occurred less than 12 months from the last facility citation of Reporting Requirements dated 08/02/2024. Additionally, a citation is issued for Health related Services [80075(a)(b)] Is issued for facility failing to ensure that C3 receives necessary medication on two different occasions. LPA counseled Licensee on Regulations pertaining to medications, reporting requirements, and personal rights of clients in care.

Exit interview, report read, citations issued, appeal rights and report provided..

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 09/12/2024 09:40 AM - It Cannot Be Edited


Created By: Mark Jeffries On 09/11/2024 at 03:10 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: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/12/2024
Section Cited
CCR
80072(a)(1)

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(a)Except for children’s residential facilities, 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 interview with C1 and C2 being
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Licensee agrees to have all staff conduct 1 hour of client abuse identification from a CCL approved vendor. Also, Licensee has removed S3 from payroll and no longer works with clients. Licensee will contact LPA as to the class schedule on 09/13/2024 bye end of business day.
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 placed in “time-out” and holes being punched in the wall by S3. Which poses a eminent risk to clients in care.
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Type A
09/12/2024
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 the physical or emotional
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Licensee aggress to take a one hour class on Reporting Requirements including staff 1 (S1) from a CCL approved vender. Licensee will contact LPA as to the class schedule on 09/13/2024 bye end of business day.
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health or safety of any client. This requirement was not met by evidence of failure to submit SIR for the medication C3 missed on 09/01/2024. Which poses an immediate 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: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2024 09:40 AM - It Cannot Be Edited


Created By: Mark Jeffries On 09/11/2024 at 03:16 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: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/12/2024
Section Cited
CCR
80075(a)(b)

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(a) The licensee shall ensure that each client receives necessary … medical .. services…(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met by evidence of C3 missing medications on 08/15-21/2024
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Licensee agrees to take 1 hour of medication administration ad/or medication regulations class, by and approved CCL vendor.
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and 09/01-10-2024. Which poses an immediate 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: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024


LIC809 (FAS) - (06/04)
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