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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515001963
Report Date: 05/16/2024
Date Signed: 05/16/2024 01:18:16 PM


Document Has Been Signed on 05/16/2024 01:18 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:WILLOW GLEN CARE CENTERFACILITY NUMBER:
515001963
ADMINISTRATOR:ANGIE KARISFACILITY TYPE:
740
ADDRESS:1547 PLUMAS COURTTELEPHONE:
(530) 751-9900
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:60CENSUS: DATE:
05/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Angie KarisTIME COMPLETED:
01:25 PM
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LPA Hiratsuka conducted this unannounced case management visit in response to a resident who has left the facility twice and is deemed by a physician not able to leave the facility without assistance. Both times facility followed their protocol for elopements. LPA toured the facility with Administrator Angie Karis.

The first time the resident left the resident was not deemed an elopement risk. When the resident was returned to the facility the resident was put on fifteen minute checks. The resident left the facility shortly after one of the fifteen minute checks. The resident was found the second time by facility staff and was brought back to the facility. The resident now has a one-on-one staff. However, the facility staff are not allowed to physically restrain someone from leaving the facility without assistance and if the resident shows signs of wanting to leave and scales the perimeter fence the staff shall call the local police department to report the resident leaving. Administrator is currently in touch with responsible party for appropriate placement.

Further investigation is required.

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
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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