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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609011
Report Date: 05/02/2023
Date Signed: 05/02/2023 07:29:37 PM

Document Has Been Signed on 05/02/2023 07:29 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:STRAWBERRY COTTAGEFACILITY NUMBER:
197609011
ADMINISTRATOR:TAYLOR, DAVID JAMESFACILITY TYPE:
740
ADDRESS:43732 SENTRY LANETELEPHONE:
(661) 266-7995
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 6DATE:
05/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
06:53 PM
MET WITH:Ricky DesahagunTIME COMPLETED:
07:27 PM
NARRATIVE
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In conjunction with complaint visit control number 31-AS-20230427111039, Licensing Program Analyst (LPA) Rios did an unannounced CASE MANAGEMENT - Deficiencies visit. LPA met with Licensee Designee Ricky Desahagun, LPA spoke with Licensee David Taylor over the phone informed him and Ricky the purpose of the visit.

During the visit it was observed that staff #2 (S2) was working in the facility without being associated with this facility. Record review revealed S2 does have fingerprint and background clearance, but is not associated to this facility. Licensee stated S2 has worked in the facility on and off whenever coverage is needed. Interviews with residents and staff corroborate S2 has worked in the facility and provided assistance to residents.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited (Refer to LIC 809-D). A civil penalty was assessed and given (refer to LIC421BG).

Copy of this report provided, appeal form given. Exit interview conducted.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2023
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 05/02/2023 07:29 PM - It Cannot Be Edited


Created By: Evelin Rios On 05/02/2023 at 06:59 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: STRAWBERRY COTTAGE
FACILITY NUMBER: 197609011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/03/2023
Section Cited
CCR
87355(e)(2)

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All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) ....This requirement is not met as evidenced by:
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Licensee shall submit evidence of transfer request or completion of transfer/ association of staff #2 to this facility. A copy of the receipt shall be provided to CCL/LPA by POC due date.
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Based document review and interviews the Licensee did not ensure that S2 was associated to the facility. This poses an immediate health and safety or personal rights risk to cresidents 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:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2023


LIC809 (FAS) - (06/04)
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