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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200131
Report Date: 09/09/2021
Date Signed: 09/09/2021 12:57:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:IRAAS RESIDENTIAL CAREFACILITY NUMBER:
019200131
ADMINISTRATOR:MOMO R. DUOAFACILITY TYPE:
735
ADDRESS:1503 VIRGINIA STREETTELEPHONE:
(510) 289-5066
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:6CENSUS: 6DATE:
09/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Momo Duoa, AdministratorTIME COMPLETED:
01:10 PM
NARRATIVE
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On 9/9/2021 at 12:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management inspection. LPA met with Administrator, Momo Duoa.

While LPA was at the facility conducting another visit, LPA observed the following deficiency:

- LPA observed one of staff (staff 2) is not fingerprint cleared or associated to the facility. LPA was informed that this staff have been working at the facility for about a month. Administrator provided DOJ documentation. However, staff 2 was not found in the Guardian system which indicated staff is not cleared.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.


Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: IRAAS RESIDENTIAL CARE
FACILITY NUMBER: 019200131
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2021
Section Cited

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Criminal Record Clearance. Obtain a California clearance or a criminal record exemption as required by the Department or...
This requirement is not met as evidence by:
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Based on record review, licensee did not comply with the section cited above by having uncleared staff working which poses an immediate health and safety risk to the clients in care.
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Civil penalty of $500 is being assess.

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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2021
LIC809 (FAS) - (06/04)
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