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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602190
Report Date: 06/03/2022
Date Signed: 06/09/2022 09:51:30 AM

Document Has Been Signed on 06/09/2022 09:51 AM - 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:CASA DEL SOL RESIDENCEFACILITY NUMBER:
198602190
ADMINISTRATOR:JACOBS, DOV EFACILITY TYPE:
740
ADDRESS:11606 11602 W WASHINGTON BLVDTELEPHONE:
(323) 678-4426
CITY:CULVER CITYSTATE: CAZIP CODE:
90066
CAPACITY: 12CENSUS: 6DATE:
06/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Valorie HansonTIME COMPLETED:
04:00 PM
NARRATIVE
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***Due to system error; this report is a recreation of case management report visit date: 06/03/22. Signature is on original report hardcopy that's on file. Licensing Program Analyst (LPA) Jey Cardenas conducted a case management visit to the above facility during a complaint investigation control number 11-AS-20220526104318. LPA met with Staff#1 who was not associated to the facility. LPA Conducted a Covid-19 risk assessment.

On today 6/3/22 LPA Cardenas is assessing a civil penalty for not being associated. Staff works at skilled nursing center area and is assisting the assisted living facility. Staff indicates she has been working and assisting the AL for about a year.

Exit interview conducted, a copy of this report provided to staff, deficiency entered on LIC809D report and appeal rights provided.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2022
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 06/09/2022 09:51 AM - It Cannot Be Edited


Created By: Jey Cardenas On 06/09/2022 at 09:22 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: CASA DEL SOL RESIDENCE
FACILITY NUMBER: 198602190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/04/2022
Section Cited
CCR
97355(e)(2)

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Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement not met as evidenced by: On 6/3/22 LPA meet with staff#1 who was not associated to the facility. This poses an immediate health and safety risk.
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Submit A signed criminal background clearance transfer request LIC9182, a copy of idividuals Driver license or valid identification card and LIC508, criminal record statement by POC.

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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:Jey Cardenas
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022


LIC809 (FAS) - (06/04)
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