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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700526
Report Date: 09/06/2023
Date Signed: 09/06/2023 11:19:24 AM

Document Has Been Signed on 09/06/2023 11:19 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
SACRAMENTO AC/SC, 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:
09/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Cami Azevedo, TIME COMPLETED:
11:30 AM
NARRATIVE
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09/06/23 Licensing Program Analyst, (LPA) Kimberly Viarella made an unannounced case management visit to this facility regarding an incident that occurred on 9/1/23 when a multi-tool with a knife was confiscated from a resident's (R1's) room (number 2). The LPA identified herself, the purpose of the visit, and asked to meet with the Designated Facility Administrator. The new Administrator, Cami Azevedo, (Certificate # 6053842735, expiration 10/08/23) arrived at the facility shortly afterward and a brief interview followed.

Since June, there have been 6 incident reports pertaining to R1; 4 of the others focused on R1 not returning at the assigned times. Per R1's IPP, the police, service coordinator, and responsible party, are all contacted every time R1 returns late.

This LPA reviewed the plan of operation, R1's file, and interviewed both R1 and the new Designated Facility Administrator. The Administrator conducted an IDT and quarterly review with Kadient on 9/5/23. R1 has had their free time out of the house reduced from 8 hours to 6 hours for 6 weeks. During that time they must keep their curfew, keep their phone on, and answer all calls. House rules were reviewed regarding weapons to ensure that R1 will comply going forward. R1 was warned that another violation might lead to a conversation about eviction as weapons in this facility put other residents at risk.

Per California Code of Regulations, no deficiencies were observed or cited today during this visit. This LPA requested Change of Administrator paperwork from the new Designated Facility Administrator.

A copy of this report was provided.

Exit interview.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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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