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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850081
Report Date: 01/21/2025
Date Signed: 01/21/2025 01:01:31 PM

Document Has Been Signed on 01/21/2025 01:01 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:STADIUM PLACE HOMEFACILITY NUMBER:
425850081
ADMINISTRATOR/
DIRECTOR:		CINDY BAKERFACILITY TYPE:
734
ADDRESS:961 STADIUM PLACETELEPHONE:
(805) 691-9036
CITY:SOLVANGSTATE: CAZIP CODE:
93463
CAPACITY: 5CENSUS: 5DATE:
01/21/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:08 AM
MET WITH:Cindy BakerTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Rankin conducted an unannounced Case Management Incident inspection regarding a self-reported incident, which was called in to LPA on 01/17/25 at 11:39 a.m. and followed up with documented Unusual Incident/Injury Reports (LIC 624) and SOC 341. Two (2) reports were received on 01/17/25, regarding Client 1 (C1), and Client 2 (C2). LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Stephanie Cole. LPA met with Administrator, Cindy Baker and RN Consultant Donna Pieprzycki and explained the reason for the visit.

Incident reports stated Staff 1 (S1) was verbally abusive to C1 and C2. Included in the reports were documented statements from witnesses of the alleged abuse as well as interviews conducted with each client regarding the incidents. Administrator was proactive in their response, immediately contacting the witnesses, reaching out to LPA Rankin for guidance, and QAS Cole to report incidents. S1 was put on administrative leave pending the investigation results. Additionally, the program started staff training the same day as this allegation was brought to their attention. Training regarding Abuse and Mandated reporting was started 01/17/25, copies of signed training log was provided to LPA.

During todays visit the LPA and QAS interviewed the Administrator and RN Consultant. At 11:32 a.m. LPA and QAS interviewed C1 and at approximately 12:00 p.m. an interview was started with C2.

Facility will provide LPA with proof of training completion and notify LPA if S1 returns. No immediate health and safety concerns were observed during the visit and no deficiencies cited at this time.

Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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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