<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202594
Report Date: 09/09/2022
Date Signed: 09/09/2022 12:18:05 PM

Document Has Been Signed on 09/09/2022 12:18 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:COMMUNITY SOLUTIONS CRISIS RESIDENTIALFACILITY NUMBER:
435202594
ADMINISTRATOR:VICKI PACHECOFACILITY TYPE:
772
ADDRESS:115 MADRONE AVENUETELEPHONE:
(669) 888-3182
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 15CENSUS: 12DATE:
09/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Vicki PachecoTIME COMPLETED:
12:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management visit and met with Administrator, Vicki Pacheco, Program Supervisor, Angelica Suud and Director of Quality Assurance and Compliance, Chris Mullins. The purpose of the visit was to obtain additional information on the multiple AWOLs reported to the Department.

During visit, LPA toured the facility to include the bedrooms, bathrooms, office, medication room, laundry room, kitchen, and backyard. All fire exits were free and clear of obstruction.

Between 07/29/2022 - 08/30/2022, the facility reported 4 AWOL incident reports to the Department. 3 out of 4 incidents occurred within the same week. All AWOL incidents were reported to law enforcement immediately, in which a missing persons was filed. 3 out of 4 incidents included a case number from law enforcement. Staff will follow-up with LPA on the case number not located for R4 by 09/12/2022.

Facility is a short-term voluntary program. Staff cannot force the clients to stay at the facility if they choose to leave, but staff encourage and persuade the clients to continue the program, as best as they can. LPA reviewed the facility's procedures for the certain incidents reported. If a client AWOLs, the facility has a procedure to contact law enforcement immediately, appropriate teams / agencies, and the client's conservator and responsible party, if applicable. If a client AWOLs, the facility will hold their bed for a certain amount of time. Staff has a procedure for clients who want to leave the facility Against Medical Advice (AMA).

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Vicki Pacheco, Angelica Suud, and Chris Mullins and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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 1