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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804056
Report Date: 07/16/2024
Date Signed: 07/16/2024 04:10:02 PM

Document Has Been Signed on 07/16/2024 04:10 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:
07/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Charisma Nieves Mari, Administrator/LicesenssTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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At approximately 2:40 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 suicide threats by C1 as reported via incident reports (IRs) dated 6/15/2024 and 6/30/2024. LPA requested copies of C1's most recent medication list and notes from all of C1's psychiatry visits since last case management visit, 5/15/2024. Per Licensee/Administrator, C1 has not had any updates to her Individual Service Plan (ISP) by her Behaviorist since facility's last case management visit where LPA obtained a copy of C1's most recent ISP.

Incident Report Dated 6/15/2024: resulted in 911 being called, transporting C1 to the ER by ambulance, and subsequently C1 being placed on a 51/50, 72 hour hold for psychiatric evaluation.

Incident Report Dated 6/30/2024: resulted in 911 refusing C1 the requested ambulance transportation to the ER and facility taking C1 instead. C1 was discharged the same day without any changes to medication or care plan.

Per Administrator/Licensee, C1's care team has informed her that it is believed that C1 calling the Crisis Center and 911 as reported in the aforementioned IRs stems from C1's autism related attention seeking behaviors rather than from depression or actual suicidal ideations. LPA was informed that C1's care team has initiated weekly individual therapy sessions through Kaiser to help with coping skills rather than C1 going to the ER and calling 911. Additionally, Kaiser was out to the facility last Friday, 7/12/2024, to conduct an evaluation of C1 to determine eligibility for their Telehealth Mental Complex Needs group support services. Also, the Regional Center is working with Turning Point Services to enroll C1 in a Transitional Support Services program. Turning Point came to facility yesterday, 7/16/2024, conducted an evaluation, and approved C1 for the program which she will begin in approximately 2-3 weeks.

Continued on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FALCON HIGH
FACILITY NUMBER: 486804056
VISIT DATE: 07/16/2024
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continued from LIC809...

Administrator/Licensee states that Kaiser has blocked C1 from messaging her doctor directly because C1 was sending 5-10 messages per day. Now, facility staff access C1's Kaiser portal to send any messages C1 requests be sent to care team. Also, the local police department flagged C1's phone number due to contacting them 4-5 times per day with illegitimate reports and requests. Administrator/Licensee states that the police department told C1 that they will arrest her for making illegitimate contacts to them moving forward. C1 was instructed to have facility call from the main phone number in the event that anything rises to a serious level indicating a reasonable need for police assistance so they know the call it legit.

Per Administrator/Licensee, C1 has ideations only but does not have a history of engaging in self-harm, injurious or aggressive behaviors towards others. LPA was informed that currently when C1 has the urge to call 911, she surrenders her phone to staff voluntarily and this plan is working for them. It has been over two weeks since the last incident, Administrator/Licensee believes progress if being made, and C1 states "I don't want to go to jail."

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/Licensee. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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