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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700703
Report Date: 12/28/2023
Date Signed: 12/28/2023 01:34:06 PM

Document Has Been Signed on 12/28/2023 01:34 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PAULSON COMMUNITY- YOSEMITE HOME, THEFACILITY NUMBER:
502700703
ADMINISTRATOR:HEKIMIAN, ARENFACILITY TYPE:
735
ADDRESS:2804 PAULSON RDTELEPHONE:
(559) 228-3056
CITY:TURLOCKSTATE: CAZIP CODE:
95380
CAPACITY: 5CENSUS: 5DATE:
12/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica Villasenor, Program Team LeadTIME COMPLETED:
02:00 PM
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On 12/28/23, Licensing Program Analyst (LPA) Renee Campbell arrived at the facility to conduct a case management visit at approximately 10 am. LPA Campbell met with Jessica Villasenor, Program Team Lead and explained the purpose of the visit.

As a result of an incident report received 12/20/23, LPA Campbell requested and observed the contact information for the staff involved in the incident. A resident roster, and the file for R1 and R1’s intervention plan was provided as well. LPA Campbell interviewed other residents in the facility and found that two had been consistently harassed by R1.

Over the course of the visit, LPA Campbell learned R1 has continually struck out at staff and been sexually inappropriate with other residents. Although a Safety Plan has been put in place, it is not affective. As a result, the Program Team Lead will request a meeting with R1’s Service Coordinator and the Administrative Coordinator to discuss and put in place new/affective or increased interventions that will ensure other residents’ safety.

An exit review was conducted and a report provided.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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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