<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200772
Report Date: 10/13/2022
Date Signed: 10/13/2022 06:29:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20221007140840
FACILITY NAME:REVITALIZE CARE HOME LLCFACILITY NUMBER:
079200772
ADMINISTRATOR:DACE, GENEVIEVEFACILITY TYPE:
735
ADDRESS:1913 CARDIFF DRTELEPHONE:
(925) 705-8635
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 6DATE:
10/13/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Genevieve Dace/Licensee and
Rachelle Wormely/House Manager		TIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared adults caring for residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Rachelle Wormely, house manager, and informed the purpose of visit. Genevieve Dace, licensee, arrived at around 3:00 pm.

It was alleged that S1, S2 and S3 are working at the facility and not fingerprint cleared LPA obtained copies of staff schedule which showed S1 on September 2022 schedule. S3 was only listed for 1 day on October 2022 for training. LPA inferviewed staff (S4, S5 and S6) who confirmed S1 works in the facility. LPA also confirmed that the director of operations (S2) comes to the facltity and comes in contact with residents. LPA checked the Department's Guardian Portal which showed S1 not fingerprint cleared and S2 not on the system. Facility does not have no document from Care Provider Mangement Bureau and/or Department of Justice to prove that S2 is fingreprint cleared.

........contnued next page (9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20221007140840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: REVITALIZE CARE HOME LLC
FACILITY NUMBER: 079200772
VISIT DATE: 10/13/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on information gathered, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 California Code of Regulations (see 9099D). A $1,000.00 civil penalty is assessed for deficiency section 80019(e)(1)). Failure to submit proof of correction by plan of correction due date may result on additional civil penalty.

Deficiency and plan, and proof of correction were discussed with Genevieve Dace.

Exit interview conducted. Appeal Rights, LIC421BG, LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20221007140840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: REVITALIZE CARE HOME LLC
FACILITY NUMBER: 079200772
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2022
Section Cited
CCR
80019(e)(1)
1
2
3
4
5
6
7
80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant..... shall prior to working, residing or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department.
1
2
3
4
5
6
7
Licensee will not have S1 and S2 work in the facilty until fingerprinted and associated. Licensee to have S2 go for fingerprinting.
A self-ceritication and copy of LIC9163 to be submitted by 10/14/2022.

A $1,000.00 civil penalty is assessed.
8
9
10
11
12
13
14
-This requirement is not met as evidenced by:
-Based on records review, interview and checking of the Department's Portal, the licensee did not comply with the section above for not having S1 and S2 not fingerprint cleared which poses immediate risks to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4