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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202842
Report Date: 11/15/2024
Date Signed: 11/15/2024 11:32:23 AM

Document Has Been Signed on 11/15/2024 11:32 AM - 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:YAI RIVERSIDE EBSHFACILITY NUMBER:
445202842
ADMINISTRATOR/
DIRECTOR:		SILVA SANTOS, STEPHANIEFACILITY TYPE:
737
ADDRESS:479 RIVERSIDE RDTELEPHONE:
(831) 240-4566
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 3CENSUS: 2DATE:
11/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Kayla WilliamsTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and Kayla Williams, Lead Registered Behavior Technician (RBT). The purpose of the visit was to follow up on two incident reports that the facility self-reported to the Department.

The first incident was reported on 10/14/2024 and occurred on 10/12/2024. The incident involved staff S1 and S2 entering resident R1's bedroom once per hour to check in on R1 instead of remaining in the bedroom to provide continuous supervision during the night shift from 7 PM to 7 AM. S1 and S2 left their telephone numbers with staff S3 and told S3 to call them if there was any issue with R1 between their hourly checks.

R1's Individualized Behavioral Support Plan (IBSP) states that when R1 is awake from 10:00 PM to 6:30 AM, R1 requires two staff members within 0-10 feet and in line of sight in bedroom or sitting outside R1's bedroom door. When R1 is asleep from 10:00 PM to 6:30 AM, R1 requires two staff within 0-10 feet or sitting outside R1's bedroom door within line of sight. The second staff will do visual check-ins with R1 every 10 minutes and also check in with the first staff.

The second incident was reported on 11/08/2024 and occurred on 11/07/2024. The incident involved resident R1 reporting that S4 touched R1's thigh. R1 stated that S4 told R1 that S4 would buy R1ice cream if R1 did not tell anyone about the incident. During visit, LPA conducted a telephone interview with Administrator (ADM) Stephanie Silva Santos, who stated that S4 has been suspended and there is an ongoing investigation. ADM provided LPA Marrufo with the police report number for the incident involving S4 and R1.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information. A civil penalty of $250 is being assessed for a violation repeated within 12 months. See LIC421FC for more information. This report was reviewed with Kayla Williams and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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Document Has Been Signed on 11/15/2024 11:32 AM - It Cannot Be Edited


Created By: David Marrufo On 11/15/2024 at 10:59 AM
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: YAI RIVERSIDE EBSH
FACILITY NUMBER: 445202842

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2024
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee agrees to submit a Plan of Correction to CCL by POC date stating how the licensee shall train staff on ensuring that all residents' care and supervision needs are met, including following supervision requirements as specified in residents' Individualized Behavioral Support Plans.
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Licensee did not ensure that staff S1 and S2 provided resident R1 with continuous, line-of-sight supervision as necessary to meet R1's needs, which posed an immediate safety risk to residents in care.
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Once training is completed, the licensee agrees to submit training records including names and dates of staff trainings, training topics, and names and qualifications of trainers to CCL.

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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: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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