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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236801775
Report Date: 07/13/2021
Date Signed: 07/13/2021 04:01:39 PM

Document Has Been Signed on 07/13/2021 04:01 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:EQUINOX CARE FACILITY LLCFACILITY NUMBER:
236801775
ADMINISTRATOR:AJEL, AGNESFACILITY TYPE:
740
ADDRESS:38281 S HWY 1TELEPHONE:
(707) 884-4061
CITY:GUALALASTATE: CAZIP CODE:
95445
CAPACITY: 9CENSUS: 8DATE:
07/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Agnes AjelTIME COMPLETED:
04:15 PM
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At approximately 2:45PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility to conduct a case management visit in regards to an incident report received on 06/04/2021. A resident was making claims against facility staff and was becoming increasingly hostile. Facility communicated with responsible party and physician and received an adjustment for medications. There have been no further incidents. Facility will work with responsible person to have the physician report updated and will address this behavior in the care plan. Facility followed regulation for reporting incidents.

No citations issued.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2021
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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