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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561703832
Report Date: 10/24/2022
Date Signed: 10/24/2022 04:00:36 PM

Document Has Been Signed on 10/24/2022 04:00 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:JOSEPHINE'S MANORFACILITY NUMBER:
561703832
ADMINISTRATOR:RICHARD T. CARINO IIFACILITY TYPE:
735
ADDRESS:575 SUNKISTTELEPHONE:
(805) 483-2006
CITY:PORT HUENEMESTATE: CAZIP CODE:
93041
CAPACITY: 6CENSUS: 6DATE:
10/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Ryan CarinoTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Angel Ascencio and Tri-Countiy Regional Center Quality Assurance Liaison (QA) Liz Aced-Arnett conducted a Case Management visit regarding an incident report and SOC 341 received on 10/21/22 regarding two (2) clients. LPA met with Administrator Ryan Carino at 10:10 a.m.

During today's visit, LPA and QA reviewed Client #1 (C1) and C2 medical files at 9:45 a.m. It was revealed that C1 has been living at the home for about 1 month and has a diagnosis of Psychiatric disorder, Schizophrenia, PTSD, and Obisity. C2 has been living the home for about seven (7) years and has a diagnosis of Mild Intellectual Disability, Secondary Parkinsonism, Psychosis, impulse Disorder, and Epilepsy. During Admin interview at 10:10 a.m., it was revealed that on 10/19/2022, C2 told Admin that C1 has touched C2 inappropriately. Admin continued, C2 stated it has been happening several times and this time she wanted to tell staff about it. Admin also added they proceeded to speak with C1 regarding the situation. C1 was visibly upset, angry and denied the allegation. Admin continued, both C1 and C2 had been friends before and continue to be after the situation. Since the incident, the staff moved C1 to another room. Admin also added that the staff have been seating C1 and C2 apart, perform nigh checks every hour, and Regional Center authorized a 1:1 for C2. During interview with C1 starting at 10:38 a.m., it was revealed on Wednesday 10/19/2022, some of the clients were sitting in the living room, including C1 and C2, having a conversation. C1 added that C2 jokingly began saying that C1 and C2 had a sexual relationship at night. C1 added they became upset and approached C2 asking them why they would make those allegations when they were not true. Interview with C2 starting at 10:50 a.m. revealed that there was two (2) sexual incidents that had occurred between C1 and C2: 1 incident happened about 5 weeks ago, the other happened on Wednesday 10/19/2022. C2 added that the incident on 10/19/2022 happened around 1:00 a.m. C2 was laying in bed, C1 went over to C2 to cover them up. C2 described that C1 touched their breast area and nothing else happened.
Based on evidence gathered, there was no citations made during today's visit. Copy of the report provided to Admin via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
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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