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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602627
Report Date: 01/19/2023
Date Signed: 01/19/2023 04:45:55 PM

Document Has Been Signed on 01/19/2023 04:45 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CALIFORNIA MENTOR - 230TH STREET HOMEFACILITY NUMBER:
198602627
ADMINISTRATOR:ROSAS, CLAUDIOFACILITY TYPE:
735
ADDRESS:434 W 230TH STREETTELEPHONE:
(909) 483-2505
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 3CENSUS: 3DATE:
01/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Shannon Hamling TIME COMPLETED:
03:14 PM
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On 01/19/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA met with Shannon Hamling and explained the purpose of the visit.

During aN initial complaint inspection visit on 01/18/23, LPA observed on Personnel Report LIC 500 staff #1 (S1) Jazmin Gonzalez Licensed Vocational Nurse on scheduled Monday - Friday 6am - 2pm. (S1) has criminal clearance background, however, (S1) is not associated employee at this facility. The facility is in violation of
80019 Criminal Record Clearance.

In review of client's files, LPA identified two of the three clients are over the age of 60 years. Client #1 (C1) was admitted on 06/09/19 and Client #2 (C2) was admitted on 05/29/19. The facility is retaining clients over 60 years and must must submit a Age Exception from Community Care Licensing (CCL) for (C2). The facility is in violation of 85068.4 Acceptance and Retention Limitations.

California Code of Regulations (Title 22, Division 6, Chapter 1), deficiencies were observed, and citations were issued (ref. LIC 9099-D).

An exit interview was conducted and a copy of the Evaluation Report and Appeal Rights were provided to Shannon Hamling.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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 01/19/2023 04:45 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 01/19/2023 at 02:11 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: CALIFORNIA MENTOR - 230TH STREET HOME
FACILITY NUMBER: 198602627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited
CCR
80019(f)(1)

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80019 (f) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility...(1) A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02)
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The Licensee/Administrator shall review the Title 22 Section 90091 regulations and comply. The administrator shall associate all staff in Guardian prior to employment. Proof of correction must be sent by due date: 01/20/23.
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This requirement is not met as evidenced by:
Based on record review, the facility failed to associate staff #1 (S1) in Guardian with LIC 9182. This violation which poses/posed an immedidate health, safety or personal rights risk to persons in care.
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IMMEDIATE CIVIL PENALTY
Type B
02/02/2023
Section Cited
CCR85068.4(c)(1-5)

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85068.4 Acceptance and Retention Limitations (c) When a licensee admits or retains any person 60 years of age or older, the licensee shall ensure that all of the following information is contained in the person's file: 1) Completed Functional Capabilities Assessment, required by Section 80069.2...
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The Licensee/Administrator shall review the Title 22 Section 85068.4 regulations and comply. The administrator shall send a request for age exceptions for clients 60 years of age and over by the POC due date: 02/02/23
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This requirement is not met as evidenced by:
Based on LPA’s observation, interview and record review, Client #1-#2 (C1) and (C2) are over 60 years old. The facility does not have approved age exceptions for any of the clients. This violation which poses/posed a potential 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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023


LIC809 (FAS) - (06/04)
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