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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602255
Report Date: 10/06/2021
Date Signed: 10/06/2021 06:32:05 PM

Document Has Been Signed on 10/06/2021 06:32 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:CALIFORNIA MENTOR - DOMINGUEZ HOMEFACILITY NUMBER:
198602255
ADMINISTRATOR:SIGNEY, RACHELFACILITY TYPE:
735
ADDRESS:214 E DOMINGUEZTELEPHONE:
(909) 483-2505
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 3CENSUS: 3DATE:
10/06/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:LINDA SMIThTIME COMPLETED:
03:30 PM
NARRATIVE
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On 10/05/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit at this facility. LPA was greeted by registered nurse Linda Smith and explained the purpose of the visit is in association with the health and safety check visit conducted on 09/28/21.

During the inspection visit on 09/28/21, the administrator revealed that client #1 (C1) is in the process of being relocated to another licensed facility. The Area Director Jeri Miles had sent out a Notice to (C1's) family representatives and Harbor Regional Center Service Coordinator effective 08/16/21. The notice indicated Harbor Regional Center has not been able to locate a new residence for (C1) and therefore California Mentor will be extending the 30-day discharge notification. The management failed to cross-report this information with Community Care Licensing Division on LIC 624. The deficiency requires the assessment of a citation. This act is a violation of Title 22, Division 6 Chapter 1.

A citation is issued, civil penalties assessed, and an exit interview conducted with Linda Smith.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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 10/06/2021 06:32 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/06/2021 at 02:55 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
MONTERY PARK, CA 91754

FACILITY NAME: CALIFORNIA MENTOR - DOMINGUEZ HOME
FACILITY NUMBER: 198602255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2021
Section Cited
CCR
80061(a)(E)

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80061 Reporting Requirements (a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section. (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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Licensee agrees to adhere to the regulations and will ensure that all clients in care incidents are reported under Title 22 Regulations section 80061. The licensee will review Regulations 80061 and submit a LIC 624 to CCLD.
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This requirement is not met by evidence: Based on observation and record review the licensee failed to adhere to reporting requirements associated with (C1)'s physical or emotional health or safety. This violation poses potential Health and Safety or Personal Rights risks to clients in care.
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This citation was corrected during the visit. A discussion with Area Director and administrator was conducted and an incident report was submitted on 09/30/21.

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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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021


LIC809 (FAS) - (06/04)
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