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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700526
Report Date: 08/05/2022
Date Signed: 08/09/2022 11:04:26 AM

Document Has Been Signed on 08/09/2022 11:04 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MIH-3 CARE HOMEFACILITY NUMBER:
502700526
ADMINISTRATOR:RYAN, MICHAELFACILITY TYPE:
735
ADDRESS:5413 FARMERS LNTELEPHONE:
(209) 244-3898
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY: 4CENSUS: 4DATE:
08/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Cami AzevedoTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility August 5, 2022 at 10:30 a.m. for a Case Management - Incident visit. LPA met with Administrator, Cami Azevedo and explained the purpose of the visit.

LPA received an incident report documenting on July 7,2022 Resident 1 informed facility staff she signed out of the facility at 5:15 p.m and met up with a man she met on "party line" who took her to the Modesto Cemetery. Resident 1 engaged in sexual activities at the cemetery with the man. LPA received an incident report documenting on July 8, 2022 Resident 1 signed out of the facility at 2:45 p.m.and met with an individual at a park, a person Resident 1 knows from day program. The two engaged in sexual activities at the park inside the girls bathroom.

Resident 1 has as history of these behaviors. Resident 1 has put in her notice and will be relocating to another facility.

LPA reviewed Resident1's IPP, and spoke with facility Administrator Cami Azevedo. The facility is doing what is necessary at this time to assist in preventing these behaviors. Resident 1 has taken relationship classes at Central Valley Training Center. The facility has brought up these behaviors at every quarterly meeting with Resident 1's Service Coordinator. The facility has informed, and actively involved the Valley Mountain regional center (VMRC) in assisting with Resident 1's behaviors. The facility has behaviorist that speaks to Resident 1 specifically about these behaviors. VMRC has brought a Psychiatrist specifically to interview Resident 1 about these behaviors. The facility Administrator and caregivers regularly speak with Resident 1 about the consequences of these behaviors. The facility is self reporting all incidents related to Resident 1.

No deficiencies cited today per Title 22 Regulations.

Exit interview conducted with Administrator Cami Azevedo and a copy of this report along with appeals rights provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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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