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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608358
Report Date: 11/10/2021
Date Signed: 11/10/2021 02:35:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LA POSADA IN SAN DIMASFACILITY NUMBER:
197608358
ADMINISTRATOR:LUCY PARKERFACILITY TYPE:
740
ADDRESS:1452 GOLDRUSH STREETTELEPHONE:
(909) 599-2273
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:6CENSUS: 6DATE:
11/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:Administrator, Lucy ParkerTIME COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vasallo conducted a Case Management - Deficiencies visit to issue deficiencies for staff not having criminal record clearances. During a complaint investigation, LPA interviewed Staff #1 (S1). LPA reviewed the staff associations for the facility and noticed S1 is not associated to the facility. LPA reviewed the fingerprint database and did not find S1's name cleared in the system. Administrator does not have a personnel folder for S1. Therefore, a deficiency was issued along with civil penalties.

Exit interview held. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LA POSADA IN SAN DIMAS
FACILITY NUMBER: 197608358
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/12/2021
Section Cited

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Personnel Requirements - General
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or
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Deficiency was evidenced by the following:
S1 is present in the facility providing care and supervision to residents. S1 is not associated to the facility and facility does not have proof of fingerprint clearance.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021
LIC809 (FAS) - (06/04)
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