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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202671
Report Date: 08/08/2024
Date Signed: 08/08/2024 05:05:24 PM

Document Has Been Signed on 08/08/2024 05:05 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:EDRICBOYLYNN RESIDENTIAL CARE HOME INCFACILITY NUMBER:
435202671
ADMINISTRATOR/
DIRECTOR:		REMEDIOS SINGSONFACILITY TYPE:
735
ADDRESS:1307 PARK PLEASANT CIRTELEPHONE:
(408) 929-4958
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 6DATE:
08/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Remedios SingsonTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management - Incident visit and met with Administrator (ADM) Remedios Singson.

On 8/5/2024, around 6:00PM, resident R1 left the facility..

On 8/7/2024, CCL office received the incident report regrading resident R1.

On 8/8/2024, LPA interviewed ADM. ADM stated R1 has 1:1 caregiver from 7:00AM - 10:00PM from Monday through Sunday. ADM stated on 8/5/2024, around 6:00PM, R1 wanted to leave the facility. ADM stated R1's 1:1 caregiver redirected R1 and encourage R1 to stay in the facility, but R1 insisted to leave the facility. The facility staff S1 called police immediately. ADM stated on 8/6/2024, around 8:06AM, a staff found R1 was at the parking in front of a grocery store. S1 notified ADM immediately. ADM went to the parking after receiving the notice and called police. Police officers came to the parking lot and encouraged R1 to return to the facility, but R1 refused. ADM asked police officers to send R1 to EPS. Police officers interviewed and talked to R1. The police officers refused to send R1 to EPS because R1 responded to police officers normally. ADM called SARC service coordinator to come to help. SARC service coordinator was able to encourage R1 to return back to the facility. ADM picked up R1 to the facility on 8/6/2024 around 4:30PM. ADM stated R1 is normal after returning to the facility.

LPA requested R1's physician report, Appraisals/Needs and Service plan, IPP and the facility protocol for elopement.

Exit interview was conducted with ADM. The reports were provided to ADM for signature. A copy of the reports was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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