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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602255
Report Date: 01/14/2022
Date Signed: 01/14/2022 06:11:59 PM

Document Has Been Signed on 01/14/2022 06:11 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: 2DATE:
01/14/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:John HamlingTIME COMPLETED:
04:47 PM
NARRATIVE
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On 01/14/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management health and safety inspection visit at this facility. LPA was greeted by John Hamling Direct Support Provider and explained the purpose of the visit. Claudio Medina is not available at the facility and was given information by telephone.

The Department was made aware the facility failed to adhere to the facility's COVID Mitigation Plan. The facility failed to report to Community Care Licensing Department two (2) staff who tested positive on 01/08/22 and 01/12/22. The facility also failed to quarantine staff for 10 days from the date of their positive test, having the staff return to work on 01/10/22 and 01/14/22. Based on the information gathered, the licensee violated the California Code Regulations (CCR) of Title 22 sections 80061 and 80064 Division 6 Chapter 1.

Deficiencies are issued and an exit interview is conducted with John Hambling.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/14/2022 06:12 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 01/14/2022 at 02:58 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: 01/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/19/2022
Section Cited
CCR
80061(b)(1)(H)

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80061 Reporting Requirements ( b)Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours... written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days...(H) Epidemic outbreaks.
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Licensee is to immediately adhere CCLD’s COVID Mitigation Plan and Title 22 section 80061. A written plan for CCLD will be submitted for approval. This citation must be corrected immediately by POC 01/19/22.
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This requirement is not met by evidence:
Based on information gathered the licensee failed follow the CCLD Mitigation Plan. The facility was not reporting positive cases and quarantine staff for 10 days. The facility did not have documentation submitted to CCLD. This violation possesses an immediate Health and Safety risk to residents in care.
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Type B
01/19/2022
Section Cited
CCR80064(a)(3)

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80064 Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications:(3) Knowledge of and ability to comply with applicable law and regulation.

This requirement is not met by evidence:
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Licensee is to will review and adhere to Title 22 section 80064. A written plan for CCLD will be reviewed and approved. This citation must be corrected immediately by POC 01/19/22.
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Based on information gathered the administrator stated he did not know he had to report epidemic cases to CCLD. The licensee did not have knowledge of and ability to comply with applicable law and regulation.This violation possesses a potential Health and Safety risk to residents 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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2022


LIC809 (FAS) - (06/04)
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