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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601776
Report Date: 12/15/2021
Date Signed: 12/15/2021 02:36:31 PM

Document Has Been Signed on 12/15/2021 02:36 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
MONTEREY PARK, CA 91754
FACILITY NAME:LONE STAR BOARD & CAREFACILITY NUMBER:
198601776
ADMINISTRATOR:OTIS ALEXANDERFACILITY TYPE:
735
ADDRESS:5140 CRENSHAW BLVDTELEPHONE:
(562) 544-5170
CITY:LOS ANGELESSTATE: CAZIP CODE:
90043
CAPACITY: 35CENSUS: 18DATE:
12/15/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:48 AM
MET WITH:Direct Care Staff, Semaj “Leon” FloydTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Troy Agard conducted an unannounced visit for the purpose of issuing a civil penalty assessment and to obtain signatures for an amended complaint investigation.
LPA met with Caregiver, Semaj Floyd and the purpose of the visit was discussed.

During a review of staff roster it was discovered that the above Caregiver is not associated to the facility.

Facility was cited for failure to request a transfer of a criminal record clearance as specified in Section 80019 and civil penalties were assessed



An exit interview was held. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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 12/15/2021 02:36 PM - It Cannot Be Edited


Created By: Troy Agard On 12/15/2021 at 12:05 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LONE STAR BOARD & CARE
FACILITY NUMBER: 198601776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2021
Section Cited
CCR
80019(e)(2)

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80019(e)(2) Criminal Record Clearance All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or...
This requirement is not met as evidenced by:
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Licensee shall ensure that said staff is associated to the facility by submitting a LIC 9182 and/or by untilizing Guardian to associate to the facility by POC due date.

Immediate Civil Penalty of $500 accessed on the LIC421BG.
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Based on observation record review, the licensee did not comply with the section cited above. LPA observed Caregiver Semaj Floyd, has a Criminal Record Clearance but is not associated to the facility. This poses an immediate health, safety or personal rights risk 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:Angela J Kendrick
LICENSING EVALUATOR NAME:Troy Agard
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2021


LIC809 (FAS) - (06/04)
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