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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600412
Report Date: 07/12/2022
Date Signed: 07/12/2022 12:58:07 PM


Document Has Been Signed on 07/12/2022 12:58 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
CENTRAL COAST SC/RES, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:R.E.F.U.G.E.FACILITY NUMBER:
015600412
ADMINISTRATOR:SYLVIA SMITHFACILITY TYPE:
733
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:6CENSUS: 3DATE:
07/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Silvia Smith, AdminstratorTIME COMPLETED:
01:00 PM
NARRATIVE
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On July 12, 2022, at 10:45 AM, LPA's George Karkazis and Alyssa Ng, made an unannounced inspection and met with Kurmonie Govan, direct care staff. Upon arrival, we discovered that there was no Facilty Manager nor House Manager present. At 11:17 AM, Silivia Smith (Facility Manager) arrived. Silvia stated that she had to leave for an appointment that could not be cancelled. There is a current census of four clients. Two clients are on AWOL and three clients were present.


LPA Karkazis is issuing a citation of Short-Term Residential Program (STRTP) Interim Licensing Standards (ILS) Section 87065(f) Personnel Requirements. See attached LIC 809-D.

An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Silvia Smith, whose signature confirms this receipt.
SUPERVISOR'S NAME: Isabel MendozaTELEPHONE: (650) -266-855
LICENSING EVALUATOR NAME: George KarkazisTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
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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Document Has Been Signed on 07/12/2022 12:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST SC/RES, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: R.E.F.U.G.E.
FACILITY NUMBER: 015600412

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2022
Section Cited

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87065 Personnel Requirements
(f) The licensee shall designate at least one facility manager to be present at the facility at all times when one or more children are present:
This requirement is not met as evidenced by:
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Based on LPA's observation, the licensee did not ensure a facility manager was on-site at all times children are present due to the facility manager leaving while three residents were present. This poses a potential Health, Safety, or Personal Rights risk to residents in care.
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Administrator will send POC on 7/15/22 by 11:59 PM.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Isabel MendozaTELEPHONE: (650) -266-855
LICENSING EVALUATOR NAME: George KarkazisTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
LIC809 (FAS) - (06/04)
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