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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602623
Report Date: 02/18/2020
Date Signed: 12/14/2022 05:45:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/14/2020 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20200214141430
FACILITY NAME:VISTA DEL MAR VILLASFACILITY NUMBER:
198602623
ADMINISTRATOR:CHEN, DERICKFACILITY TYPE:
740
ADDRESS:3049 EAST DEL MAR BLVDTELEPHONE:
(626) 215-1045
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 3DATE:
02/18/2020
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee, Christina Chen
Administrator, Derrick Chen		TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Uncleared fingerprint staff is working in the facility.
INVESTIGATION FINDINGS:
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***This amended report superseded the Licensing Report dated 2/18/2020***
Licensing Program Analyst (LPA) Tao conducted an Initial 10-Day complaint investigation regarding the above allegation. LPA discussed the purpose of the visit with Licensee, Christina Chen.
The investigation consisted of the following: LPA interviewed Staff #1 - Staff #4 including the Licensee and Administrator; obtained and reviewed staff roster/personnel report, and Staff #3 (S3) personnel files.
Allegation #1: Unfingerprinted staff are working in the facility. Review of S3 files, the investigation revealed, S3 reported staff began working at the facility as a caregiver from 05/02/2019 to 02/18/2020, did not have a criminal record clearance and had never been associated to the facility. Per facility association, dated 02/14/2020, showed S3 was not associated to the facility. Based on LPA's records review and staff interviews conducted, the facility failed to obtain a criminal record clearance for S3 prior to working at the facility, therefore, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED.
The following deficiency was cited per California Code of Regulations, Title 22. Refer to 9099D. Civil penalties are being issued in the amount of $500.00 for the period from 05/02/2019 to 02/18/2020.
Exit interview held with the Licensee and administrator. A copy of the report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20200214141430
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VISTA DEL MAR VILLAS
FACILITY NUMBER: 198602623
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/19/2020
Section Cited
CCR
87355(e)(1)
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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.
This requirement is not met as evidenced by:
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Administrator shall ensure that all staff obtain a Criminal Record Background Clearance and are associated to the facility prior to employment. Uncleared persons cannot return to work until they are cleared and associated to the facility.
Submit copies of Livescan and transfer requests by POC due date
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Based on review of records, Staff #3 is not cleared. LPA reviewed records from regional office and verified that the staff is not cleared. Violation of Section 87355(e) shall result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the Department. Civil penalties are being assessed in the amount of $500.00. This poses an immediate health and safety risk to residents
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POC is cleared on 6/10/2020
CCR
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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: Fernando FierrosTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3