486804246-5-7-2025-21-AS-ECOS-DGFRSW-20250507131726

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804246
Report Date: 05/07/2025
Date Signed: 05/07/2025 01:17:33 PM

Document Has Been Signed on 05/07/2025 01:17 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:	4 SEASONS		FACILITY NUMBER:	486804246
ADMINISTRATOR/ DIRECTOR:	MATHURIN, HERBY		FACILITY TYPE:	735
ADDRESS:	907 HARLEQUIN WAY		TELEPHONE:	(415) 629-1205
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY: 5		CENSUS: 3	DATE:	05/07/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:40 AM
MET WITH:	Jodian Allen-		TIME VISIT/ INSPECTION COMPLETED:	01:26 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 Analysts (LPAs) conducted a case management inspection, on 5/7/25 at approximately 11:40pm, and met with staff, Jodian Allen. LPAs reviewed three incident reports on client #1 (C1), and reviewed client file/records. LPAs interviewed staff regarding the incidents. Incidents occurred on 3/21/25, 4/6/25, and 4/14/25. C1 had an assigned 1-1 staff from Maxim Healthcare from 8am to 4pm. On 4/6/25, at approximately 9:36am, C1 awol from a restaurant out in the community while with their assigned 1-1 staff, S1. S1 was not able to see the client in line of their sight and called Police regarding client AWOL. Per incident report, S1 lost sight of client within 10 seconds of getting to where C1 had climbed over the fence from the restaurant when AWOL. On 4/14/25, at approximately 1:45pm, C1 AWOL from the facility while in front of the home with Maxim Healthcare assigned staff, S1, and Maxim Healthcare Supervisor/BCBA. Per incident report, C1 left the facility upset/angry, and 1-1 Maxim Healthcare staff chose to not follow the client, stating if the client went out of sight, Police would be called. C1 AWOL out of line of sight to the Maxim Healthcare staff, and BCBA /Supervisor called the Police. During the time of both incidents above, 4/6 and 4/14, C1 was being supervised by a 1-1 assigned staff from Maxim Healthcare. LPAs discussed .with Administrator Heby Mathurn, to ensure updating care plan of C1 to include AWOL behavior and plan of action to address client AWOLs. Administrator to ensure to bring any concerns regarding care and supervision of C1 with assigned 1-1 staff to North Bay Regional Center's attention and ensure concerns are addressed, and all involved are on the same page. Administrator to ensure C1's care needs are met by the facility's plan of care, staffing care and supervision needed, including how AWOLs are addressed. No deficiencies cited during today's inspection. Exit interview conducted with the Administrator Herby Mathurn.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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