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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340300163
Report Date: 02/16/2022
Date Signed: 02/16/2022 04:46:31 PM

Document Has Been Signed on 02/16/2022 04:46 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,
, CA
FACILITY NAME:HELEN E. COWELL CHILDREN'S CENTERFACILITY NUMBER:
340300163
ADMINISTRATOR:ANNETTE JUMPERFACILITY TYPE:
733
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 16CENSUS: 9DATE:
02/16/2022
TYPE OF VISIT:Case Management - MedicationsUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Erica Arreygue, Health Services CoordinatorTIME COMPLETED:
05:00 PM
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SB 484 Psychotropic Medication Inspection

An announced SB 484 Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Hillary Hall on February 16, 2022 at 9:30am. During the inspection, LPA Hall met with Erica Arreygue, Health Services Coordinator, and Annette Jumper, Administrator and inspected the facility inside and out.

LPA reviewed five client records on site at the facility.
LPA reviewed three staff personnel files on site at the facility.
LPA reviewed five of child’s psychotropic medications and medication records.
LPA interviewed three staff on site.

LPA interviewed three of children currently taking psychotropic medication. One child refused to be interviewed. One was not on site due to a home visit.

LPA provided a signed copy of this LIC-809 Report to the Health Services Coordinator and conducted an exit interview on this date.

No deficiencies are being cited at this time. LPA will return on February 17, 2022 to complete the inspection.
SUPERVISORS NAME: Daniel Allmon
LICENSING EVALUATOR NAME: Hillary Hall
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2022
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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