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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202842
Report Date: 08/22/2024
Date Signed: 08/22/2024 12:17:16 PM

Document Has Been Signed on 08/22/2024 12:17 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: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: 1DATE:
08/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Dvawntre LattimoreTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Assistant Administrator Dvawntre Lattimore.

The purpose of the visit was to follow up with LIC624 Unusual Injury/Incident Reports (IRs) self-reported by the facility and submitted to the Department. On 08/11/2024, the facility submitted two IRs related to the same incident that occurred on 08/11/2024 at approximately 8:00 AM. The incident involved staff S1 and S2 and resident R1. S1 was assigned to provide one-on-one supervision of R1 while R1 was in the living room area of the facility. S2 was nearby in the facility kitchen area. S1 left R1 to go to the bathroom without notifying S2 that S1 would be leaving R1. S2 then left the kitchen area to go into the facility office that is located inside the facility garage. During visit, LPA observed a hallway between the kitchen area and the garage area that has been converted to an office. The office door has a keypad lock and the door automatically closes. S2 returned to the living area and observed that S1 was not providing one-to-one supervision of R1. When S1 returned, S2 told S1 that S1 did not provide one-on-one supervision of R1 and S1 made verbally aggressive statements to S2 in the presence of R1.

During visit, LPA Marrufo reviewed R1's Individualized Behavioral Support Plan that was dated 07/09/2024. Page 73 of R1's Individualized Behavioral Support Plan states that from 6:30 AM to 10:00 PM, R1 requires a 1:1 staff member within 0-10 feet and an Emergency Intervention Professional (EIP) at a distance to hear and support during behaviors of concern. During interview on 08/22/2024, Assistant Administrator Dvawntre Lattimore stated staff S1 was assigned as R1's 1:1 staff and S2 was assigned as R2's EIP staff.

See LIC809-C for more information. Page 1 of 2.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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 3
Document Has Been Signed on 08/22/2024 12:17 PM - It Cannot Be Edited


Created By: David Marrufo On 08/22/2024 at 11:07 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: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2024
Section Cited
CCR
80072(a)(1)

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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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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 the personal rights of residents are upheld at all times, including the rights of residents to be accorded dignity in their relationships with staff. Once training is completed,
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This requirement was not met as evidenced by: Licensee did not ensure that staff S1 was verbally aggressive to staff S2 while in the presence of resident R1, which poses an immediate personal rights risk to residents in care.
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the licensee agrees to submit training records including names and dates of staff trainings, training topics, and names and qualifications of trainers to CCL.
Type A
08/23/2024
Section Cited
CCR80078(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: Licensee did not ensure that a staff provided 1:1 care within 0-10 feet of resident R1 and that an
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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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Emergency Prevention Professional was within hearing distance of R1, as required in resident R1's Individualized Behavioral Support Plan, which poses 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.
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: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 EBSH
FACILITY NUMBER: 445202842
VISIT DATE: 08/22/2024
NARRATIVE
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On 08/17/2024, the facility submitted an IR reporting a medication error that occurred on 08/17/2024. After review of the IR and after interviewing Assistant Administrator Dvawntre Lattimore, LPA determined that the incident was actually a medication refusal by the resident and not a medication error. LPA Marrufo obtained a copy of the recorded medication refusal from the resident's record during visit. LPA Marrufo advised Administrator Silva Santos that staff can indicate medication refusals as the Type of Incident when reporting to CCL.

On 08/14/2024, the Department submitted an IR stating that staff provided local police department officers shift notes and a written internal investigation regarding an alleged case of sexual abuse that R1 reported to have occurred outside of the facility. Administrator Stephanie Silva Santos stated during visit that the facility does not have a written policy regarding the requirement to obtain consent from a resident before providing personal medical information to local law enforcement agencies.

LPA Marrufo conducted a health and wellness check with resident R1 during visit. LPA Marrufo observed R1 to be observed by two staff while in R1's bedroom.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D page for more information.

This report was reviewed with Administrator Stephanie Silva Santos and a copy of this report and appeal rights were provided.

Page 2 of 2.

END REPORT
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3