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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803543
Report Date: 04/14/2023
Date Signed: 04/14/2023 12:09:29 PM

Document Has Been Signed on 04/14/2023 12:09 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:
04/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Facility Manager, Dorisetta Ruben
Prospective Administrator, Mohonned Justice		TIME COMPLETED:
12:30 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), Farhaan Sarangi arrived unannounced Inclusion Specialized Programs LLC-Whisperglen for the purpose of following-up on an incident report that was forwarded to the Regional Office (RO) on March 15, 2023. LPA met with Facility Manager, Dorisetta Ruben, and was granted access into the facility. Prospective Administrator, Mohonned Justice arrived 30 minutes later.

CCL received an incident report reflecting a medication error. The error occurred on March 14, 2023 due to facility manager giving the wrong medication to Client #1 (C1) (See LIC 809D). Prescribing physician was notified and the Placement Agency was notified of the medication error. During an interview with the Administrator on April 14, 2023, Administrator acknowledged that the facility manager dispensed the wrong medication to a client in care.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 1 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given to the Administrator along with this report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2023
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 04/14/2023 12:09 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 04/14/2023 at 07:46 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: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2023
Section Cited
CCR
80075(b)

1
2
3
4
5
6
7
80075(b)-Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Plan of Correction (POC) will include retraining all staff on medication procedures, proper documentation on the MAR and following physicians prescribing instructions. In addition, Licensee shall provide a self-certification of this regulation and how future compliance will be met.
8
9
10
11
12
13
14
Based on review of the incident report dated for March 15, 2023, the licensee did not comply with the section cited above due to Client #1 being administered the wrong medication which poses an immeidate health, safety and personal rights risk to clients in care.
8
9
10
11
12
13
14
POC due on April 17, 2023

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023


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