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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603180
Report Date: 10/05/2023
Date Signed: 10/05/2023 11:24:10 AM

Document Has Been Signed on 10/05/2023 11:24 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:RAECHELLE CARE HOMEFACILITY NUMBER:
198603180
ADMINISTRATOR:BERG, TIAFACILITY TYPE:
735
ADDRESS:2215 W 15TH STTELEPHONE:
(323) 656-8266
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY: 30CENSUS: 30DATE:
10/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Maria VasquezTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a complaint investigation visit and discovered that C-1's file was not accessible. Per Ms. Berg, files for clients that have been discharged from this facility are archived. During the investigation visit, LPA requested Ms. Berg (numerous times) for documentation pertaining to C-1. Ms. Berg did not provide the requested documents.

Deficiency cited. Refer to LIC 809D for the continuation of this report.

Exit interview conducted, appeal rights and a copy of this report was provided to Martin Espinoza.

Note: LPA was experiencing technical difficulties during this visit. Report will be emailed to Ms. Berg (Administrator).
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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 10/05/2023 11:24 AM - It Cannot Be Edited


Created By: Elizabeth Irra On 10/05/2023 at 10:47 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RAECHELLE CARE HOME
FACILITY NUMBER: 198603180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2023
Section Cited
HSC
80070(d)

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Client Records-All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This standard is not met at evidence by: Ms. Berg did not provided LPA with C-1's requested documentation during visit.
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Administrator to provide the following documents for C-1: facesheet, appraisal needs and services plan, physician's report, exit/discharge documentation and documentation that C-1 took all of their belongings including any P&I monies that were at this facility prior to C-1's discharge.

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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:Tony Vasallo
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


LIC809 (FAS) - (06/04)
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