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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600744
Report Date: 04/30/2024
Date Signed: 04/30/2024 02:32:35 PM

Document Has Been Signed on 04/30/2024 02:32 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:R.E.F.U.G.E.IIFACILITY NUMBER:
015600744
ADMINISTRATOR/
DIRECTOR:		GEORGE JORDON IIFACILITY TYPE:
733
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6CENSUS: 4DATE:
04/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Reine De Ceil, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 4-30-24 1:45PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at REFUGE 2, and met with Reine De Ciel, Administrator.

During records review, REFUGE 2’s COA Accreditation had expired on 10-31-23. The facility is being cited for National Accreditation ILS 87089(a).

While conducting interviews and document research for complaint #14-CR-20240301142809 dated 3-1-24, LPA discovered that incident reports were not written or sent to Community Care Licensing (CCL) or authorized representatives regarding client AWOLs, dates 2-26-24, 2-27-24. The facility is being cited for ILS Reporting Requirements 80061(b).

An exit interview was conducted, appeal rights provided and a copy of this report was given to Reine De Ciel, Administrator.
SUPERVISORS NAME: Isabel Diego
LICENSING EVALUATOR NAME: George Karkazis
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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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Document Has Been Signed on 04/30/2024 02:32 PM - It Cannot Be Edited


Created By: George Karkazis On 04/30/2024 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: R.E.F.U.G.E.II
FACILITY NUMBER: 015600744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
ILS
87089(a)

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87089(a) A short-term residential therapeutic program shall obtain national accreditation from an entity identified by the Department pursuant to Welfare and Institutions Code Section 11462(b)(6)(A).

This requirement is not met as evidenced by:
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Facility is to obtain Accreditation, COA Accreditation expired 10-31-23. Licensee has stated that they are in process of renewal. Facility must immediately submit any correspondence regarding renewal to LPA via email to George.Karkazis@dss.ca.gov. by 5-31-24
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Based on record review, the licensee did not comply with the section cited above, COA Accreditation expired 10-31-23, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
05/15/2024
Section Cited
ILS80061(b)

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80061(b) Upon the occurrence, during the operation of the facility.... a report shall be made to the licensing agency within the agency's next working day ....... submitted to the licensing agency within seven days following the occurrence of such event.

This requirement is not met as evidenced by:
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Licensee shall write and send incident reports for AWOLs on 2-26-24, 2-27-24. Licensee agrees to hold a training on reporting requirements, time frames, and procedures, including ensuring written reports by email or other written communication to authorized representatives and initial reports to the licensing agency incident reporting line. The training /sign in sheets, and IR’s shall be sent to George.Karkazis@dss.ca.gov by 5-15-24.
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Based on record review and interviews, the Licensee did not comply with the section above, there are no incident reports in the San Bruno Incident Report Inbox for C1(see LIC 811 Confidential Names List), for incidents dated 2-26-24, 2-27-24,. which poses a potential health, safety or personal rights risk to persons in care.
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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 Diego
LICENSING EVALUATOR NAME:George Karkazis
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
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