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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001749
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:14:56 PM


Document Has Been Signed on 10/11/2022 03:14 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ARVILINH HOME CAREFACILITY NUMBER:
306001749
ADMINISTRATOR:ARVIN BUMANGLAGFACILITY TYPE:
740
ADDRESS:9351 MELBA DRIVETELEPHONE:
(714) 643-9077
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 5DATE:
10/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Arvin Bumanglag
Linh Nguyen		TIME COMPLETED:
03:35 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20221004201130. LPA met with Administrator (AD) Arvin Bumanglag and Registered Nurse (RN) Linh Nguyen and explained the reason for today’s visit.

LPA conducted a complaint investigation regarding allegations, facility failed to accord resident with privacy and facility failed to obtain approval to install cameras in residents' rooms. During the course of the investigation, LPA interviewed staff present at the facility, and determined that an uncleared individual was presently working at the facility.

LPA conducted an interview with AD Arvin Bumanglag who stated that the individual had worked at the facility before and had been associated. LPA conducted a record review of the facility on Guardian and determined the individual is not currently associated. Per AD, the uncleared individual had been back working at the facility for “one day.” LPA informed AD that all individuals prior to working, residing or volunteering in a licensed facility must obtain a California clearance or a criminal record exemption as required by the Department.


Based on the interviews conducted and records reviewed during the investigation, violations are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties in the amount of $100 per violation per day are being assessed. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was provided at the end of the visit.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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 10/11/2022 03:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: ARVILINH HOME CARE
FACILITY NUMBER: 306001749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2022
Section Cited

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
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This requirement is not met as evidence by;

LPA conducted interviews and a record review of the facility on Guardian and determined an uncleared individual was presently working at the facility.
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 prior to being cleared and associated.

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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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
LIC809 (FAS) - (06/04)
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