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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004556
Report Date: 05/17/2023
Date Signed: 05/18/2023 10:55:54 AM


Document Has Been Signed on 05/18/2023 10:55 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:CASA DE LUZFACILITY NUMBER:
507004556
ADMINISTRATOR:JOHANNA WESTFACILITY TYPE:
740
ADDRESS:3509 SCENIC DRTELEPHONE:
(209) 578-3077
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 6DATE:
05/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Maria Andrade TIME COMPLETED:
02:30 PM
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On 05/17/2023 at 12:45am, Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct a case management visit. LPA was greeted by Facility Designated Representative, Maria Andrade and explained the purpose of the visit. There were 3 other staff members present at this time, Taylor Andrade, Marvin Chy, and Alethia Alvarez.

Current census was 6. A brief interview with FDR Andrade was conducted.

The purpose of this visit was to follow up on an incident that was received by the department on 05/10/2023 and 05/16/2023.

On 05/16/2023 the department received an incident report that stated that R1 eloped from the facility. R1 has eloped from the facility previously on 05/10/2023. On 05/10/2023, the resident informed staff that they were going to leave to visit their former residence. The resident left without signing out at 12:30pm and did not return home. On 05/16/2023, the resident left at 8:30am without signing out. He did not return home by 8:00pm for medication rounds. At that time staff called the police and notified them of a missing resident. At 1:02am, the resident was returned back home.

LPA reviewed R1's physicians report, needs and appraisals plan, facility house rules, and AWOL action plan. R1 is able to leave the facility without assistance.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's visit. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
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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