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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320037
Report Date: 08/23/2022
Date Signed: 08/23/2022 12:24:30 PM

Document Has Been Signed on 08/23/2022 12:24 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:CARMIE HOME CAREFACILITY NUMBER:
198320037
ADMINISTRATOR:RECIO, PAOLOFACILITY TYPE:
735
ADDRESS:14528/30 HALLDALE AVETELEPHONE:
(310) 938-2190
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY: 9CENSUS: 8DATE:
08/23/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Rosauro De GuzmanTIME COMPLETED:
12:30 PM
NARRATIVE
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On 8/23/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced case management visit for deficiencies observed during investigation of complaint 11-AS-20210622163519 on 8/23/2022. LPA met with staff Rosauro de Guzman and explained the purpose of today’s visit is to issue citations and was granted permission to enter the premises.

During records review LPA Cifuentes noted that file for C1 was not present in the facility and administrator was unable to provide the file at a later date. LPA also noted that no incident report was available for C1.

California Code of Regulations (Title 22, Division 6, Chapter 1), the above-mentioned deficiencies were observed, and citations issued (809-D)

An exit interview was conducted, and a copy of the report and Appeal Rights were provided to Staff Rosauro de Guzman.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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 08/23/2022 12:24 PM - It Cannot Be Edited


Created By: Stephanie Cifuentes On 08/23/2022 at 11:51 AM
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
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: CARMIE HOME CARE
FACILITY NUMBER: 198320037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2022
Section Cited
CCR
80070(g)

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Client Records
Original client records or photographic reproductions shall be retained for at least three years following termination of service to the client.
This requirement was not met as evidenced by:
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Administratrator will review regulation 80070 in it entirety. A self-certification statement shall be submitted to CCLD via email or fax by POC due date.
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Based on record review and interview, records of C1 were not present at the facility after their departure. This poses a potential risk to clients health, safety and/or personal rights in care.
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Type B
09/06/2022
Section Cited
CCR80061(b)

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Reporting Requirments
Upon the occurrence...of any of the events specified in (1) below, a report shall be made to the licensing agency...In addition, a written report...shall be submitted to the licensing agency within seven days following the occurrence of such event.
This requirement was not met as evidenced by:
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Administratrator will review regulation 80061 in it entirety. A self-certification statement shall be submitted to CCLD via email or fax by POC due date.
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Bases on records review, incident report was not received for elopment of C1 from facility. This poses a potential risk to clients health, safety and/or personal rights 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 M Alvarez
LICENSING EVALUATOR NAME:Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022


LIC809 (FAS) - (06/04)
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