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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801655
Report Date: 02/04/2021
Date Signed: 02/05/2021 07:45:03 AM

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:NEW WAY GROUP HOME 2FACILITY NUMBER:
565801655
ADMINISTRATOR:MENDOZA, ALEXFACILITY TYPE:
733
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:6CENSUS: 6DATE:
02/04/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Facility Manager (FM)TIME COMPLETED:
03:00 PM
NARRATIVE
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On 02/04/2021 at 2:30pm, Licensing Program Analyst (LPA) Kevin Sauk conducted a Case Management - Incident inspection at the above-said facility, and met with the Facility Manager, in response to a Special Incident Report, submitted to Community Care Licensing (CCL) on 01/26/2021, in order to investigate a possible Personal Rights violation. The incident, which occurred on 01/26/2021, involved staff (S1), who took client's (C1's) blanket off of C1 in the morning, when C1 was refusing to get out of bed to get ready for school; this triggered C1 to approach S1 from behind, and wrap his arm around S1's neck. C1 later went to the kitchen and tore the fire extinguisher off of the wall and began to spray it in the living room. [See LIC811 Confidential Names List form (LIC811), dated 02/04/2021, for names.]

LPA interviewed staff (S1), and client (C1), who both confirmed that S1 had taken C1's blanket off of C1 in the morning to help him get out of bed; this is a personal rights violation. It was reported that this method of waking-up C1 had occurred on more than one occasion, because C1 sometimes has a hard time waking up in the morning. Regardless of whether or not this method had triggered C1, other forms of waking-up the clients from bed shall be used.

PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7.5 Version 3, the following deficiency has been cited. (See LIC809-D)

Exit interview was conducted and a copy of this report will be emailed to the Facility Manager (FM), in order to obtain a signature. Signature will be on file.
SUPERVISOR'S NAME: Rosa RodriguezTELEPHONE: (424) 301-3034
LICENSING EVALUATOR NAME: Kevin C SaukTELEPHONE: (310) 916-8922
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: NEW WAY GROUP HOME 2
FACILITY NUMBER: 565801655
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/16/2021
Section Cited

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To be free of physical, sexual, emotional, or other abuse, and from corporal or
unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion,
threat, mental abuse, or other actions of a punitive nature ...or withholding of shelter, clothing, or aids to physical functioning.
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This requirement is not met as evidenced by: S1 and C1 both confirmed that S1 had taken C1's blanket off of C1 in the morning to help him get out of bed; this occurred on more than one occasion. This poses a potential health, safety, or personal rights risk to residents 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: Rosa RodriguezTELEPHONE: (424) 301-3034
LICENSING EVALUATOR NAME: Kevin C SaukTELEPHONE: (310) 916-8922
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2021
LIC809 (FAS) - (06/04)
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