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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803543
Report Date: 12/04/2024
Date Signed: 12/04/2024 11:40:21 AM

Document Has Been Signed on 12/04/2024 11:40 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:INCLUSION SPECIALIZED PROGRAMS LLC - WHISPERGLENFACILITY NUMBER:
486803543
ADMINISTRATOR/
DIRECTOR:		JOSE HERNANDEZFACILITY TYPE:
735
ADDRESS:630 WHISPERGLEN CTTELEPHONE:
(562) 447-0991
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 4CENSUS: 3DATE:
12/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Jose Hernandez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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At approximately 10:20 AM, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator Jose Hernandez, who arrived at 11:15 AM. The purpose of the visit was to follow up on a self-reported incident that was submitted to Community Care Licensing (CCL).

Incident Report: CCL received an incident report on 10/11/2024. Report states that on 10/09/2024, Client 1 (C1) became agitated while Staff 1 (S1) was preparing him for bed. Staff 2 (S2) came in to assist. C1 swung at S2 and made contact. S2 did not use proper CPI techniques; reacting and making contact with C1's face. S1 was able to de-escalate situation. S2 was sent home per facility protocol. S2 was terminated that day as Licensee has a zero-tolerance for staff not following CPI training and protocols. Facility made all appropriate notifications per regulation.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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