PART 1
PART 1
GROUP HOME
STRTP
COMMUNITY TREATMENT CENTER
TRANSITIONAL HOUSING PLACEMENT PROVIDER
YOUTH HOMELESS PREVENTION CENTERS
TRANSITIONAL SHELTER CARE FACILITY
TEMPORARY SHELTER CARE FACILITY
LICENSED CAPACITY
CURRENT CENSUS
6 BEDS
FACILITY
Please Select
MUIR WOOD ADOLESCENT FAMILY SERVICES (#496803428) 1733 SKILLMAN LN, PETALUMA CA 94952.
MUIR WOOD LLC - 1743 SKILLMAN (#496800005) 1743 SKILLMAN LN, PETALUMA CA 94952
MUIR WOOD LLC - SKILLMAN EAST (#496890083) 1336 SKILLMAN LN, PETALUMA CA 94952
MUIR WOO LLC - HANNAN RANCH (#496890074) 621 HANNAN RANCH LN, PETALUMA, CA 94952
MUIR WOOD LLC - LOHRMAN SOUTH (#496890062) 900 LOHRMAN LN. PETALUMA, CA 94952
MUIR WOOD LLC - REBECCA STREET (#496890065) 402 REBECCA ST. PETALUMA, CA 94952
MUIR WOOD LLC - MAGNOLIA (#496890076) 2055 MAGNOLIA AVE. PETALUMA, CA 94952
MUIR WOOD LLC - COLD SPRINGS (#496890056) 6868 COLD SPRINGS RD. PENNGROVE, CA 94951
MUIR WOOD LLC - PENNGROVE SOUTH (#496890087) 6851 COLD SPRINGS RD. PENNGROVE, CA 94951
MUIR WOOD LLC - SONOMA MOUNTAIN (#496890088) 501 SONOMA MOUNTAIN RD. PENTALUMA, CA 94954
MUIR WOOD AUBERRY ROAD (#107207237) 18685 AUBERRY RD. CLOVIS, CA 93619
MUIR WOOD AUBERRY SOUTH McKenna (#107207243) 12820 AUBERRY RD. CLOVIS, CA 93619
MUIR WOOD BRADLEY RANCH (#337900136) 1830 BRADLEY ST. RIVERSIDE, CA 92506
MUIR WOOD DAVINCI (#337900118) 2225 DAVINCI STREET RIVERSIDE, CA 92506
MUIR WOOD EDGEWILD (MARY) (#337900137) 2320 MARY ST. RIVERSIDE, CA 92506
TYPE OF INCIDENT
AGGRESSIVE ACT - CLIENT TO CLIENT
AGGRESSIVE ACT - CLIENT TO STAFF
AGGRESSIVE ACT - STAFF TO CLIENT
AGGRESSIVE ACT - OTHER TO CLIENT
AGGRESSIVE ACT - CLIENT TO OTHER
BEHAVIOR EPISODE
AGGRESSIVE ACT - UNKNOWN
SUBSTANCE ABUSE
UNAUTHORIZED
ABSENCE (AWOL)
HARM TO SELF
CSE RELATED
PSYCHOLOGICAL
PROPERTY DAMAGE
NON-PHYSICAL AGGRESSION
THEFT
ALLEGED SEXUAL ABUSE - SEXUAL
ALLEGED SEXUAL ABUSE - PHYSICAL
ALLEGED SEXUAL ABUSE - PSYCHOLOGICAL
FINANCIAL
NEGLECT
Other
IF MULTIPLE CHILDREN INVOLVED, FOLLOW DESIGNATION "C1" FOR CHILD 1 AND SO ON
CHILD INVOLVED
TYPE OF PLACEMENT
AGE
GENDER
DATE OF ADMISSION
C1:
C2:
C3:
C4:
AGENCIES/INDIVIDUALS NOTIFIED: C1
NAME
PHONE NUMBER
LICENSING
LAW ENFORCEMENT
PLACEMENT AGENCY
AUTHORIZED REPRESENTITIVE
AGENCIES/INDIVIDUALS NOTIFIED: C2
NAME
PHONE NUMBER
LICENSING
LAW ENFORCEMENT
PLACEMENT AGENCY
AUTHORIZED REPRESENTITIVE
AGENCIES/INDIVIDUALS NOTIFIED: C3
NAME
PHONE NUMBER
LICENSING
LAW ENFORCEMENT
PLACEMENT AGENCY
AUTHORIZED REPRESENTITIVE
AGENCIES/INDIVIDUALS NOTIFIED: C4
NAME
PHONE NUMBER
LICENSING
LAW ENFORCEMENT
PLACEMENT AGENCY
AUTHORIZED REPRESENTITIVE
WERE DE-ESCALATION TECHNIQUES USED PRIOR TO CONTACTING LAW ENFORCEMENT?
YES
NO
IF YES, EXPLAIN THE TECHNIQUES USED. IF NO, EXPLAIN WHY NOT.
WAS LAW ENFORCEMENT CONTACTED AS LAST RESORT ONCE ALL OTHER DE-ESCALATION AND INTERVENTION TECHNIQUES HAD BEEN EXHAUSTED?
YES
NO
WAS SUPERVISOR APPROVAL OBTAINED PRIOR TO CONTACTING LAW ENFORCEMENT?
YES
NO
IF NO, EXPLAIN WHY NOT.
LOCATION OF INCIDENT
FACILITY
SCHOOL
OTHER
IF OTHER, EXPLAIN WHERE
DESCRIPTION OF INCIDENT. INCLUDE NATURE OF INCIDENT, ACTION TAKEN BY STAFF IN RESPONSE TO THE INCIDENT, AND DISPOSITION OR CURRENT STATUS OF THE INCIDENT. FOR INCIDENTS IN GROUP HOMES, INCLUDE A DESCRIPTION OF THE EVENTS LEADING UP TO THE INCIDENT.
WAS MEDICAL TREATMENT REQUIRED FOR CLIENT?
YES
NO
IF YES, LIST NAME OF ATTENDING PHYSICIAN, FINDINGS, AND TREATMENT, IF ANY.
DOES THE INCIDENT INVOLVE THE USE OF MANUAL RESTRAINTS? IF YES, ATTACH A SEPARATE SHEET REPORTING INFORMATION REQUIRED BY SECTION 84061(h)(6)OF TITLE 22 REGULATIONS.
YES
NO
PREPARRED BY
NAME
TITLE
DATE PREPARED
-
Month
-
Day
Year
Date
REVIEWED/APPROVED BY
NAME
TITLE
DATE APPROVED
-
Month
-
Day
Year
Date
PART 2
FACILITY
Please Select
MUIR WOOD ADOLESCENT FAMILY SERVICES (#496803428) 1733 SKILLMAN LN, PETALUMA CA 94952.
MUIR WOOD LLC - 1743 SKILLMAN (#496800005) 1743 SKILLMAN LN, PETALUMA CA 94952
MUIR WOOD LLC - SKILLMAN EAST (#496890083) 1336 SKILLMAN LN, PETALUMA CA 94952
MUIR WOO LLC - HANNAN RANCH (#496890074) 621 HANNAN RANCH LN, PETALUMA, CA 94952
MUIR WOOD LLC - LOHRMAN SOUTH (#496890062) 900 LOHRMAN LN. PETALUMA, CA 94952
MUIR WOOD LLC - REBECCA STREET (#496890065) 402 REBECCA ST. PETALUMA, CA 94952
MUIR WOOD LLC - MAGNOLIA (#496890076) 2055 MAGNOLIA AVE. PETALUMA, CA 94952
MUIR WOOD LLC - COLD SPRINGS (#496890056) 6868 COLD SPRINGS RD. PENNGROVE, CA 94951
MUIR WOOD LLC - PENNGROVE SOUTH (#496890087) 6851 COLD SPRINGS RD. PENNGROVE, CA 94951
MUIR WOOD LLC - SONOMA MOUNTAIN (#496890088) 501 SONOMA MOUNTAIN RD. PETALUMA, CA 94954
MUIR WOOD AUBERRY ROAD (#107207237) 18685 AUBERRY RD. CLOVIS, CA 93619
MUIR WOOD AUBERRY SOUTH (#107207243) 12820 AUBERRY RD. CLOVIS, CA 93619
MUIR WOOD BRADLEY RANCH (#337900136) 1830 BRADLEY ST. RIVERSIDE, CA 92506
MUIR WOOD DAVINCI (#337900118) 2225 DAVINCI STREET RIVERSIDE, CA 92506
MUIR WOOD EDGEWILD (MARY) (#337900137) 2320 MARY ST. RIVERSIDE, CA 92506
DATE OF INCIDENT
-
Month
-
Day
Year
Date
DATE OF FOLLOW UP
-
Month
-
Day
Year
Date
WAS ANY CHILD RESIDING IN THE FACILITY ALLEGED TO HAVE COMMITTED A CRIME?
YES
NO
LIST ANY CHILD INVOLVED (WHETHER OR NOT ALLEGED TO HAVE COMMITTED A CRIME), INCLUDE CHILD(REN) FROM ORIGINAL INCIDENT (PART 1):
NAME
GENDER
RACE
ETHNICITY
AGE
C1:
C2:
C3:
C4:
LIST ANY STAFF INVOLVED
NAME
POSITION
1
2
3
4
WHO INITIATED CONTACT WITH LAW ENFORCEMENT?
STAFF
OTHER YOUTH
NEIGHBOR
OTHER
UNKNOWN
TYPE OF OUTCOME
5150
COUNSELLED BY LAW ENFORCEMENT
MENTAL HEALTH EVALUATION
UNKNOWN
ARREST(S) MADE
JUVENILE HALL
STAFF DISCIPLINARY ACTION
DETAINED BY LAW ENFORCEMENT
INTERVIEWED BY LAW ENFORCEMENT
RETURNED TO FACILITY
PLACEMENT TERMINATED
LAW ENFORCEMENT DID NOT RESPOND
Other
(If any boxes above are checked, explain briefly here and include any additional information. Attachadditional sheets as needed.)
PREPARED BY
NAME
TITLE
DATE PREPARED
-
Month
-
Day
Year
Date
REVIEWED BY
NAME
TITLE
DATE REVIEWED
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: