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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275390021
Report Date: 05/13/2022
Date Signed: 05/16/2022 09:47:29 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/16/2022 09:47 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CHERISH RECEIVING CENTERFACILITY NUMBER:
275390021
ADMINISTRATOR:ADAM WEINERFACILITY TYPE:
722
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6CENSUS: DATE:
05/13/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Adam WienerTIME COMPLETED:
03:30 PM
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On 5/12/22 at 10:40am, Licensing Program Analyst (LPA) Paul Simien conducted an unannounced visit to the above facility. The purpose of this visit was to conduct the continuation required annual inspection started on 2/25/22. LPA met with Adam Weiner, Core Program Director II (CPD), at the above facility to conduct the required annual inspection.

The following items were discussed and reviewed by LPA during Inspection:

1.LIC 500 reviewed to ensure appropriate staffing ratios, including Administrator, Social Work personnel, and Direct Care staff. 2. Personnel files obtained/reviewed to ensure staff meet regulatory requirements. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Personnel Files are retained at the office and are available to the department for review upon request. 3. Facility procedures for 30-day updates to CCLD regarding participant Overstay logs discussed 4. Facility is to ensure all clients considered for placement have been assessed as meeting placement eligibility requirements. Facility has process in place to contact
authorized representatives to ensure assessment for clients’ continued placement. 5. Disaster and Mass Casualty Plan was reviewed with CPD. 6. LPA went over the Intake process with CPD. 7. LPA reviewed one client file with CPD.

No deficiencies were found but LPA made recommendations regarding training log and keeping the Administrator files with the rest of the staff's files (LPA was still able to view the Administrator files, except the Training log which will be sent next week due to being stored with HR)

No deficiencies were cited at this time. LPA conducted an exit interview with Adam Weiner, CDP, at 3:30PM.
SUPERVISORS NAME: Helga Wong
LICENSING EVALUATOR NAME: Paul Simien
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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