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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430701864
Report Date: 07/22/2024
Date Signed: 07/22/2024 01:33:54 PM

Document Has Been Signed on 07/22/2024 01:33 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LYTTON GARDENS COMMUNITY CAREFACILITY NUMBER:
430701864
ADMINISTRATOR/
DIRECTOR:
ANAHI MCKANEFACILITY TYPE:
740
ADDRESS:649 UNIVERSITY AVENUETELEPHONE:
(650) 617-7338
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY: 55CENSUS: 42DATE:
07/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Anahi McKaneTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced case management visit and met with Administrator Anahi McKane. The purpose of the visit was to follow up with an SOC341 Suspected Adult/Elderly Abuse report submitted by the facility to CCL on 07/01/2024. The SOC341 report stated that on Sunday 06/30/2024 at 8 PM, staff S1 heard sounds coming from the living unit of resident R1 that sounded like R1's Private Duty Care Giver (PDCG1) was verbally abusing R1 and throwing around objects in R1's living unit. The SOC341 stated that R1 reported to facility staff that PDCG1 hit R1 in the lower right leg.

During visit, LPA Marrufo reviewed three video recordings that Administrator Anahi McKane stated R1 took while standing outside of R1's living unit while PDCG1 was inside. LPA Marrufo could hear the sound of someone yelling and cursing from inside R1's living unit. LPA Marrufo interviewed R1 during visit. R1 stated during interview that PDCG1 was yelling and cursing at R1 and hit R1 in the lower right leg.

During visit, LPA obtained copies of R1's Emergency Contact and Information Form, LIC602 Physician's Report, Resident Functional Evaluation, and the internal Incident Report submitted by R1 to Administrator Anahi McKane.

LPA Marrufo requests that the facility submit copies of PDCG1's contact information and Home Care Organization documentation by 07/29/2024

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Anahi McKane and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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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