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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800881
Report Date: 10/21/2021
Date Signed: 10/24/2021 11:01:40 AM

Document Has Been Signed on 10/24/2021 11:01 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SAN LUIS HOUSEFACILITY NUMBER:
216800881
ADMINISTRATOR:DUNA JOSON (AGSALOG)FACILITY TYPE:
735
ADDRESS:396 SAN LUIS WAYTELEPHONE:
(415) 897-5716
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 5DATE:
10/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Duna Joson - AdministratorTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Fernandes-Goes conducted a case management inspection due to complaint investigation. LPA arrived at the facility was welcome by staff Veronica S. There is a total of 5 clients with 2 in day program.

During this visit there were 3 staff present at the facility, however; 1 out of 3 is not associated to the facility. Staff S1 has fingerprint clearance, not associated to the facility according with Guardian Employee Roster printed on 10/21/2021. Staff S1 stated that she works at a sister facility which S1 is associated to. Facility has staff S1 working here today due to staff schedule change.

Immediate Civil Penalties are being assessed in the amount of $100 due to staff not being associated to the facility.

*****Total Civil Penalties issued today in the amount of $100.00

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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 10/24/2021 11:01 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 10/21/2021 at 10:50 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SAN LUIS HOUSE
FACILITY NUMBER: 216800881

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2021
Section Cited
CCR
80019(f)

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80019(f) Criminal Record Clearance - All individuals subject to a criminal record ... shall prior to working... licensed facility:Request a transfer of a criminal record clearance. Based on obs, interrview, record review,
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Facility administrator understands that staff must be fingerprint cleared & associated to the facility before working at facility. Facility administrator to submit an LIC 9098 self certification that
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the licensee did not comply w/section cited above in 1out of3 staff is not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
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 all staff working at the facility are fingerprint cleared & associated to facility before starting to work which should be submitted to Department by POC date of 10/22/21 is order to clear this citation. (civil penalty)

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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:Bethany Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021


LIC809 (FAS) - (06/04)
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