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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803378
Report Date: 09/13/2021
Date Signed: 09/13/2021 03:48:34 PM

Document Has Been Signed on 09/13/2021 03:48 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CARE GREATFACILITY NUMBER:
486803378
ADMINISTRATOR:ZHANG, GUOLIAN (MARK)FACILITY TYPE:
735
ADDRESS:3265 VISTA DEL LAGO WAYTELEPHONE:
(707) 427-8776
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 3DATE:
09/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Silvia Rosario, House ManagerTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Karina Canela conducted an unannounced case management inspection and met with Silvia Rosario, House Manager. The purpose of this case management inspection is to follow up on an incident which was self reported and submitted to Community Care Licensing (CCL) on 09/04/2021.

The following was reported: On 08/31/2021 at approximately 1:10 PM Client (C1) was taken on an outing by CBEM (Creating Behavioral & Educational Momentum) staff and Care Great staff (S1) and House Manager. C1 suddenly got up from an activity and kicked S1. C1 then kicked CBEM staff 1 and attempted to kick CBEM staff 2. C1 then attempted to hit House Manager and began running after House Manger. Two CBEM staff were running behind Care Great Staff (S1), who was running behind C1, who was chasing House Manager who arrived back at Care Great Facility. C1 kicked House Manager and C1 was sent to their bedroom. C1 calmed down once in their room.
C1's conservator, North Bay Regional Center Service Coordinator, and CCL were notified of the incident.

C1 has had increase in maladaptive behaviors (since July 2021) such as property destruction and physical aggression towards staff and clients. House Manager stated C1 has attacked other clients (C2 & C3) in the home and staff have intervened. House Manager has bought toys and additional items to keep C1 pre-occupied to reduce behaviors, but C1's behaviors have nit diminished.

During today's inspection LPA obtained and requested copies of documents for Client (C1). LPA and House Manager discussed 30 Day Eviction Notice procedures. LPA provided a copy of the regulation for reference.

Exit interview conducted with House Manager Silvia Rosario whose signature below confirms receipt of report.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
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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