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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001643
Report Date: 02/23/2022
Date Signed: 02/23/2022 02:01:07 PM

Document Has Been Signed on 02/23/2022 02:01 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DOSTY'S PRIVATE INCARE SERVICES IVFACILITY NUMBER:
347001643
ADMINISTRATOR:CAROLYN J. DOSTYFACILITY TYPE:
735
ADDRESS:2175 56TH AVENUETELEPHONE:
(916) 399-0287
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 6CENSUS: 5DATE:
02/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Donnisha WileyTIME COMPLETED:
02:20 PM
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On 2/23/2022 at 1:25 pm, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit to deliver the findings of the Department's investigation. Upon LPAs arrival, Caregiver Donnisha Wiley was present at facility and contacted Assistant Administrator Janae Ross to let her know LPA is at the facility. LPA Truong was screened for COVID-19 symptoms with temperature taken prior to being allowed entry into the facility. LPA spoke with Assistant Administrator Janae Ross on the phone and explained the purpose of the visit. LPA Truong read the report to Janae over the phone. Janae gives consent for staff Donnisha to sign the report.

On 11/18/2021, an investigation was conducted by the Department regarding an altercation between former clients C1 and C2 that resulted in great bodily injury (gunshot wound) to C2. The incident occurred in front of the facility with the present of staff. A case management visit was needed due to concerns that facility staff did not call 911 in a timely manner to report the incident and that staff are using/selling drugs in the facility. Throughout the course of the investigation, the Department conducted interviews and reviewed facility records. Based on the interviews and statements obtained during the investigation, it was learned that facility staff (S1) called 9-1-1 as soon as C2 was shot. S1 stated that S1 did not feel that S1 needed to call 9-1-1 because S1 was de-escalating the situation. In addition, it was learned that no client/former client or staff reported sale or use of drugs in/at the facility.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was held and a copy of this report was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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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