425850083-5-22-2024-29-AS-BPHS-D5HRQM-20240522131345

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850083
Report Date: 05/22/2024
Date Signed: 05/22/2024 01:14:16 PM

Document Has Been Signed on 05/22/2024 01:14 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	DOCTOR'S RESIDENTIAL CARE FACILITY #2		FACILITY NUMBER:	425850083
ADMINISTRATOR:	GILL, NATASHA		FACILITY TYPE:	735
ADDRESS:	2412 CESAR E CHAVEZ DR		TELEPHONE:	(702) 858-4266
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY:	4	CENSUS: 4	DATE:	05/22/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Natasha Gill, Administrator		TIME COMPLETED:	01:15 PM

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On 05/22/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced Case Management-Incident visit in collaboration with Tri-Counties Regional Center (TCRC) representative Miguel Magana. LPA and TCRC representative arrived at the facility, met with Administrator Natasha Gill, and announced the purpose of the visit.

On 05/15/2024, the Licensing Agency received an incident report stating that while Client #1 (C1) was entering an Adult Day Program (ADP) transportation van, Staff noticed four (4) distinct marks/bruises on C1's left back biceps in the shape of a hand. When asked, C1 stated the marks/bruises were caused by Staff member(s) from C1's home facility location grabbing C1 by the arm on the night of 05/14/2024. In addition to the incident report provided by the ADP, an SOC341 Report of Suspected Dependent Adult/Elder Abuse was attached.

On 05/17/2024, the Licensing Agency received an incident report from C1's home facility location, indicating that on the night of 05/14/2024 C1 had eloped from the facility after a verbal argument with another client. Facility Staff followed C1 to provide a safe escort back to the facility. When C1 noticed the Staff member following, C1 began to run away and allegedly left the sidewalk into the road where an automobile was driving which could have caused an accident. The Staff member began to run to catch C1 and prevent the automobile from hitting C1 in the street. During this process, the Staff member grabbed C1 to prevent a collision with the automobile. The Staff member injured their own ankle during this process. C1 was safely returned to the facility after this incident.

On 05/22/2024, LPA conducted interviews at the facility about the details of the incident occurring to C1. Through interviews by LPA, it was stated that C1 informed the Administrator of the facility that Staff had grabbed/pulled C1 when they had eloped, but C1 stated that the Staff had "saved their life" as C1 had run in front of a vehicle in traffic. Staff only began to run after C1 as they saw a car coming down the street and C1 was running into the street without looking. Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: DOCTOR'S RESIDENTIAL CARE FACILITY #2	FACILITY NUMBER: 425850083
	VISIT DATE: 05/22/2024

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Staff stated that they pulled C1 away from the intersection of the street to prevent the car from hitting C1. Staff stated that C1 verbally and physically relaxed after being pulled away from the vehicle in traffic. C1 stated to Staff that they were going back home after the incident and did not appear to have any physical or emotional concerns from being grabbed/pulled away from a moving vehicle in the street while eloping. Staff interviewed stated that they were thinking about saving C1 from being hit by a car, and continued to attempt to assist C1 even after personally receiving an injury to their ankle. Interviews by LPA indicated the level of traffic on the surrounding streets varies by time of day, but during the rush hour time of day when C1 eloped there are many more cars that do not fully follow the rules of the roundabouts in the area. Staff interviewed stated body checks are performed on clients daily, varying between 2-3 times. After the incident, there was not a body check performed, but Staff did verbally ask C1 about their physical and mental condition. C1 responded to feeling fine and went to sleep. When interviewed by TCRC, Staff indicated that they receive training on restraints/holds for clients including elopements.

C1 has a previous history of elopement, and was/is diagnosed PRN medications by a physician as a preventative/sedative measure. These PRN medications have been modified to reduce the strength/frequency over time while C1 is in care at the facility. The facility has documented protocol for client elopements in which the Staff member(s) are instructed to follow/walk behind a client who has eloped. If a Staff member loses sight of the client and/or more than 15 minutes of elopement have occurred then the facility will call 911 for Law Enforcement assistance. The documented elopement protocol for C1 states that C1 likes to run and Staff members need to keep pace with C1, but maintain distance as not to be perceived as a threat. The elopement protocol also states that at all times the Staff members will try to ensure the safety of C1 from street traffic. C1's personal profile has been given to Law Enforcement in 2019 at admission to the facility because of C1's history of elopement. Additionally, LPA requested and received copies of C1's Physician Report, Needs and Services Plan, Client Elopement Plan, and photographic evidence of the bruising to the left back biceps of C1.

There is no deficiency regarding Client Personal Rights for a physical abuse violation as the bruising on C1’s left biceps occurred accidentally during an elopement from the facility in which the Staff member tried to ensure the safety of C1 from being hit by an automobile in street traffic. C1 stated being very appreciative for the assistance of the Staff member and also stated no negative psychological/emotional effects from the incident.

Exit interview conducted, a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC809 (FAS) - (06/04)

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