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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800867
Report Date: 03/30/2023
Date Signed: 03/30/2023 05:17:18 PM

Document Has Been Signed on 03/30/2023 05:17 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:ARC-HERITAGE VALLEYFACILITY NUMBER:
565800867
ADMINISTRATOR:SONIA SALINASFACILITY TYPE:
775
ADDRESS:116 NORTH 10TH STREETTELEPHONE:
(805) 933-9029
CITY:SANTA PAULASTATE: CAZIP CODE:
93060
CAPACITY: 90CENSUS: 29DATE:
03/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Katie GomezTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced case management visit regarding an alleged incident on 3/7/2023. LPA met with Administrator/Program Manager Katie Gomez and explained the reason for the visit.

The alleged incident was reported to the administrator on 3/23/2023 by the parent of client 1 (C1). C1 alleged they hurt their wrist during an outing to the zoo on 3/7/2023 after they were pushed down by staff 1 (S1) and client 2 (C2).

During this visit LPA conducted interviews with four staff and one client between 9:05 a.m. and 9:55 a.m. One of the staff had been C1's support staff at the zoo and the client had been at the zoo on the same day as well. All of the clients and staff who went to the zoo stayed together as a group. Neither staff nor the client witnessed anyone arguing or fighting.

Staff who were interviewed all said if something had happened to C1, they would have known because C1 is very comfortable communicating any issues with staff.

On 3/21/23, C1's staff observed C1 wearing a wrist brace and asked C1 what happened. On that date C1 stated they hurt their wrist while at their parent's workplace. When asked how it happened C1 would not respond. C1 told staff if their wrist still hurt the next day that their parent would take them to urgent care. C1 has not returned to program since 3/21/2023.

It is also noted that C2 and S1 were not at the zoo that day. C2 has not been at day program since January 2023. S1 was working with a different group somewhere else in the community.

Based on the information obtained during these interviews, there is insufficient evidence to substantiate the allegation that S1 and C2 pushed C1 down while at the zoo on 3/7/2023.

No citations were issued during today’s visit. Exit interview conducted and the report was emailed to the administrator.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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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