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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440707795
Report Date: 07/12/2024
Date Signed: 07/12/2024 02:14:30 PM

Document Has Been Signed on 07/12/2024 02:14 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ROLLING RIDGE R.C.H.FACILITY NUMBER:
440707795
ADMINISTRATOR/
DIRECTOR:		CARLONE, MICHAELFACILITY TYPE:
735
ADDRESS:751 LARKIN VALLEY ROADTELEPHONE:
(831) 475-0888
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 12CENSUS: 8DATE:
07/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Casey ClarkTIME VISIT/
INSPECTION COMPLETED:
02:30 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) David Marrufo conducted an unannounced Case Management visit and met with Casey Clark. The purpose of the visit was to cite the facility for an incident involving a staff physically abusing a resident.

On 04/10/2024, the Department received an LIC624 Unusual Injury/Incident Report from the facility stating that S1 physically abused R1 by punching R1 in the face, causing R1 to sustain an injury to R1’s right eye.

A Department investigator investigated the incident. During the investigation, resident R2 provided credible statements about witnessing S1 punch R1. R2 observed S1 punch R1 three times in the outside patio, three times in the hallway, and once in R1’s bedroom. Based on interviews with staff, R2 does not lie and has been truthful about the past.

R1 was shown three photographs of three staff members and was asked which staff committed the assault on R1. R1 pointed to the photograph of S1.

Deficiencies have been cited as per California Code of Regulations Title 22. See LIC809-D page for more information. This report was reviewed with Casey Clark and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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 2
Document Has Been Signed on 07/12/2024 02:14 PM - It Cannot Be Edited


Created By: David Marrufo On 07/12/2024 at 01:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ROLLING RIDGE R.C.H.
FACILITY NUMBER: 440707795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2024
Section Cited
CCR
80072(a)(3)

1
2
3
4
5
6
7
Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation,
1
2
3
4
5
6
7
Licensee agrees to submit a Plan of Correction by POC date to ensure that staff are trained on upholding the personal rights of residents, including ensuring that residents are free from abuse. Once training is completed, the Licensee
8
9
10
11
12
13
14
intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not met as evidenced by: Licensee did not ensure that staff S1 did not physically abuse R1 by punching R1, which posed an immediate safety risk to residents in care.
8
9
10
11
12
13
14
agrees to submit training records to CCL that include names of staff trained, date(s) of training, and name and qualifications of trainer.
Type A
07/13/2024
Section Cited
HSC1558(a)(2)

1
2
3
4
5
6
7
1558 Persons prohibited from employment; dismissal or removal; appeal (a) The department may prohibit any person from being a member of the board of directors, an executive director, or an officer of a licensee, or a licensee
1
2
3
4
5
6
7
Licensee agrees to submit a Plan of Correction by POC date to ensure that staff are trained on upholding the personal rights of residents, including ensuring that residents are free from abuse. Once training is completed, the Licensee
8
9
10
11
12
13
14
from employing, or continuing the employment of, or allowing in a licensed facility or certified family home, or allowing contact with clients of a licensed facility or certified family home by, any employee, prospective employee, or person who is not a client who has: (2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home. This requirement was not met as evidenced by: Staff S1 engaged in conduct that is inimical to the health and safety of resident R1 by physically abusing R1.
8
9
10
11
12
13
14
agrees to submit training records to CCL that include names of staff trained, date(s) of training, and name and qualifications of trainer. Licensee agrees to ensure that S1 is no longer employed or present at the facility.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2