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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701139
Report Date: 03/17/2023
Date Signed: 03/21/2023 01:35:52 PM

Document Has Been Signed on 03/21/2023 01:35 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MY HOME SWEET CARE LLCFACILITY NUMBER:
502701139
ADMINISTRATOR:XIONG, MAIFACILITY TYPE:
735
ADDRESS:2709 MARINA DRTELEPHONE:
(209) 401-3454
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 3DATE:
03/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mai XiongTIME COMPLETED:
01:00 PM
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On 03/17/2023 at 12:00 pm, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a Case Management visit. LPA Pascua was greeted by Facility Designated Administrator, Mai Xiong and explained the purpose of the visit. The current census was 3. 2 out of 3 residents were out at their respective day program at this time.

The purpose of this visit is to follow up on an incident report that was received by the department on, 02/13/2023. The incident reported that R1 had tried to self harm themselves through taking the shower cord and wrapping it around their neck. It was also reported that 911 was called as requested by the resident and was then taken to the hospital.

LPA reviewed R1's Physician report, Need's and Appriasals, and his Behavioral reports. It was learned through these reports that the resident has a history of suicidal ideations and self injurious behavior but has never attempted to physically hurt themself. LPA also conducted an interview with facility staff and it was stated that they did know about the the extent of the residents self injurious behavior but have been in contact with East Bay Regional Center and Behavioral Health to help mitigate the resident's behavior. It was learned that the facility has had a difficult time in getting response by East Bay Regional Center.

Based on interviews and records review, Based on interview and records review there were no deficiencies that were cited during this case management visit. LPA Pascua will come at a later time if further follow up is needed.

A copy of this report was provided to the facility and an exit interview was conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
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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