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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603452
Report Date: 08/26/2022
Date Signed: 08/26/2022 08:30:05 AM

Document Has Been Signed on 08/26/2022 08:30 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DHASA CARE IIFACILITY NUMBER:
198603452
ADMINISTRATOR:CARTER, S'HALANAFACILITY TYPE:
735
ADDRESS:757 MILLBURY AVETELEPHONE:
(773) 718-0819
CITY:LA PUENTESTATE: CAZIP CODE:
91746
CAPACITY: 4CENSUS: 3DATE:
08/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:55 AM
MET WITH:Jasmin Rangel; DSPTIME COMPLETED:
08:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) David Sicairos conducted a subsequent complaint visit. LPA met with DSP Jasmin Rangel and explained the reason for the visit. Administrator S'Halana Carter was called during the visit and was provided with details of the visit. During the course of the investigation related to Complaint Control Number: 28-AS-20220315123814, it was determined that S1 did not have the appropriate and necessary training on file including no records related to sexual abuse training.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit are documented on 809D.

Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: David Sicairos
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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 08/26/2022 08:30 AM - It Cannot Be Edited


Created By: David Sicairos On 08/25/2022 at 10:56 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: DHASA CARE II
FACILITY NUMBER: 198603452

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2022
Section Cited
CCR
80065(f)(3)

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(f) All personnel shall be given on-the-job training... in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.
(3)Provision of client care and supervision...

This requirement is not met as evidenced by:
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Administrator to ensure facility staff receives on-the-job training appropriate to the job assigned. Administrator to conduct in-service training as required in the following topics: Personal Rights, Reporting Requirements and Sexual Harrasment and submit copy of attendees training sign in sheet and material of topics discussed by POC due date.
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Based on record review conducted by Investigator Hector, S1 did not have any sexual abuse training on file. This poses a potential health, safety, and/or personal rights risk to the clients 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:Stefanie Coronel
LICENSING EVALUATOR NAME:David Sicairos
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022


LIC809 (FAS) - (06/04)
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