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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803543
Report Date: 06/24/2022
Date Signed: 06/24/2022 06:16:40 PM

Document Has Been Signed on 06/24/2022 06:16 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:INCLUSION SPECIALIZED PROGRAMS LLC - WHISPERGLENFACILITY NUMBER:
486803543
ADMINISTRATOR:BALDWIN, VANESSAFACILITY TYPE:
735
ADDRESS:630 WHISPERGLEN CTTELEPHONE:
(562) 447-0991
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 4CENSUS: 2DATE:
06/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mohammed Justice, Assistant AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Walters arrived unannounced to conduct a follow up on a self-reported incident. LPA met with Assistant Administrator, Mohammed Justice. The Administrator Vanessa Baldwin was not available for today's visit. On 6/23/22 the facility self-reported an incident in which staff S1, left two clients in the facility without supervision. LPA conducted interviews with staff. Interviews reveal that S1 called the Administrator to inform them that they were leaving clients in the facility unassisted. S1 left the facility before Administrator or other staff could cover their shift. C1 and C2 were left for approximately 15 minutes on their own. The Administrator contacted the police to ensure the client's safety. LPA reviewed C1s medical records; C1 may not be out in the community unattended. The incident involved an absence of supervision. Staff was terminated.

LPA requested S1's records, however per Administrator S1 records were not in the facility. Administrator will send LPA staff records by COB 6/24/22.

Civil penalties are being assessed in the amount of $500 under section 87411(a) Personnel Requirements for absence of supervision.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2022
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 06/24/2022 06:16 PM - It Cannot Be Edited


Created By: Katrina Walters On 06/24/2022 at 10:36 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: INCLUSION SPECIALIZED PROGRAMS LLC - WHISPERGLEN
FACILITY NUMBER: 486803543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2022
Section Cited
CCR
87411(a)

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87411(a) Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers,& competent to provide the services necessary to meet resident needs. This requirement was not met. ** Based on interviews
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Staff was terminated, deffieciny was cleared during inspection. $$ A civil penalty is being applied for $500.00
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and record review, staff left c1 and C2 unattended. LIC602 Physicians rpt states that R1 is not able to leave facility unassisted. "Absence of supervision", This is an Immediate Risk to the Health and safety or resident in care.
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Katrina Walters
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022


LIC809 (FAS) - (06/04)
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