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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608120
Report Date: 09/29/2021
Date Signed: 09/29/2021 12:53:03 PM

Document Has Been Signed on 09/29/2021 12:53 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CCLE HOME CARE, LLCFACILITY NUMBER:
197608120
ADMINISTRATOR:ROSANNA TOMENENGFACILITY TYPE:
735
ADDRESS:16055 NAPA STREETTELEPHONE:
(818) 830-7383
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 4DATE:
09/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Rosanna Tomaneng TIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in order to address deficiencies related to a recent unlawful eviction.

On 9/17/21 LPA Pitz received copies of a 3-day eviction and a 30-day eviction for resident 1 (R1), both were dated 9/3/21. LPA spoke with the administrator on 9/17/21 and confirmed that no written notice was given to the client on 9/3/21, but the Responsible Party (RP) was informed verbally. On 9/5/21 R1 was picked up from the facility by their RP and RP stated that they were informed on this date that the facility was no longer able to meet R1's needs due to their change in ambulatory status.


Report reviewed, signed and delivered. Exit interview conducted, deficiencies cited on 809D page.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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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Document Has Been Signed on 09/29/2021 12:53 PM - It Cannot Be Edited


Created By: Alexander Pitz On 09/29/2021 at 12:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CCLE HOME CARE, LLC
FACILITY NUMBER: 197608120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/05/2021
Section Cited
CCR
80068.5(b)

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80068.5(b) The licensee shall obtain prior written approval from the Department to evict the client upon three (3) days written notice to quit and upon a finding of good cause.

This requirement is not met as evidenced by:
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Administrator will obtain and provide proof of training from an approved vendor, in addition to signing a statement of understanding and intent to abide the cited regulation.
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Based on interviews, the facility did not ensure that a written approval was obtained for a 3 day eviction of R1 before informing their RP that R1 could not stay at the facility which is an immediate risk to the health, safety, or personal rights of residents 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:Eva Miller
LICENSING EVALUATOR NAME:Alexander Pitz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2021


LIC809 (FAS) - (06/04)
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