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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201090
Report Date: 03/23/2023
Date Signed: 03/23/2023 03:51:06 PM


Document Has Been Signed on 03/23/2023 03:51 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:A SPRINGTIME RESIDENCEFACILITY NUMBER:
079201090
ADMINISTRATOR:TRUCKS, CHRISTINAFACILITY TYPE:
740
ADDRESS:2752 MOHAWK CR.TELEPHONE:
(415) 290-7611
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 6DATE:
03/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Isagani Silvestre, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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On 3/23/2022 starting at 3:00 PM, Licensing Program Analysts (LPA) L. Francisco and K. Nguyen conducted a case management as a result of complaint #15-AS-20230210092132. LPAs met with Administrator, Isagani Silvestre.

During the initial 10-day complaint visit on 2/15/2023, LPAs discovered that S1 was issuing the refund to R1's responsible party. However, S1 is not the designated Administrator of the facility.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted Administrator and Licensee over the phone. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
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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Document Has Been Signed on 03/23/2023 03:51 PM - It Cannot Be Edited

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: A SPRINGTIME RESIDENCE
FACILITY NUMBER: 079201090

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2023
Section Cited

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87205(a) ACCOUNTABILITY OF LICENSEE GOVERNING BODY
(a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning.. the welfare of the individuals it serves.
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By POC date, Administrator will review regulation and submit self-certification letter to CCLD.
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Based on interview and record review, Licensee did not comply with regulations cited above. LPAs observed that S1 who is not a designated Administrator issued a refund to R1's responsible party which poses a potential personal rights to persons 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
LIC809 (FAS) - (06/04)
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