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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804056
Report Date: 05/15/2024
Date Signed: 05/15/2024 03:10:09 PM

Document Has Been Signed on 05/15/2024 03:10 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FALCON HIGHFACILITY NUMBER:
486804056
ADMINISTRATOR/
DIRECTOR:		MARI, CHARISMA NIEVESFACILITY TYPE:
735
ADDRESS:2044 FALCON CTTELEPHONE:
(707) 438-9210
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
05/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Charisma Nieves Mari, Administrator/LicesenssTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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At approximately 2:10 PM Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Incident visit. LPA was greeted by Charisma Nieves Mari, Administrator/Licensee and signed the Visitor's Log. LPA informed Administrator/Licensee the purpose of today's visit was to investigate a suicide threat from C1 as reported via an incident report dated 4/29/2024 at 11:00 PM and received by CCLD on 04/30/2024. LPA requested copies of C1's most recent medication list, individual service plan created by her behaviorist, and notes from her most recent psychiatry visit. Per Licensee/Administrator, C1 has been adjusting her medications with her Psychiatrist due to feeling tired and unmotivated, but is now back on medication to help with suicidal thoughts.

Incident Report: CCL received an incident report noted above which stated that on 4/29/2024 at approximately 11:00 PM, C1 reported to staff feeling anxious again. She kept leaving her room and expressing that she could not fall asleep and and didn't feel well. A staff member offered her some tea to help alleviate her anxiousness. However, C1 reported continued feelings of restlessness and anxiety. According to the IR and interview today with Licensee, C1 stated that she began to feel she was going to be violent and wanted to hurt herself. C1 further expressed wanting to go to the ER and C1 called 911. C1 was taken to Kaiser Vacaville ER, was kept over night and released at 6:00 AM the following morning.

Facility made all appropriate notifications per regulation.

LPA requested and reviewed documents.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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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