<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002286
Report Date: 01/11/2023
Date Signed: 01/11/2023 03:33:40 PM

Document Has Been Signed on 01/11/2023 03:33 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:R & R CARE, INC.FACILITY NUMBER:
306002286
ADMINISTRATOR:ROMAN MATAGAFACILITY TYPE:
740
ADDRESS:14952 BURNHAM CIRCLETELEPHONE:
9496511830
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY: 6CENSUS: 6DATE:
01/11/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:51 PM
MET WITH:Roman Mataga - AdministratorTIME COMPLETED:
03:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced Case Management visit to R & R Care, Inc. LPA Velazquez met with Administrator Roman Mataga. During the complaint investigation visit with Complaint Number: 22-AS-20201015123210 LPA Velazquez observed Staff (S) #1 did not appear on the Facility Personnel Report Summary dated January 9, 2023.

At 2:58 PM LPA Velazquez called the Orange County Regional Office and spoke with staff who confirmed S1 was not associated to R & R Care, Inc.



Deficiencies cited under California Code of Regulations Title 22 Division 6 Chapter 8. A civil penalty was also assessed. An exit interview was conducted with Administrator Roman Mataga and a copy of this report along with the appeal rights, LIC 811, LIC 9098 and LIC 421BG were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/11/2023 03:33 PM - It Cannot Be Edited


Created By: Patricia Velazquez On 01/11/2023 at 03:03 PM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: R & R CARE, INC.
FACILITY NUMBER: 306002286

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/12/2023
Section Cited
CCR
87355(e)2)

1
2
3
4
5
6
7
Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by: based on record review and interview the licensee did not transfer S1's criminal record clearance. This poses an immediate risk to the health and safety of residents in care.
CIVIL PENALTY ASSESSED
1
2
3
4
5
6
7
Licensee to ensure all staff have proper criminal record clearance pursuant to regulation and submit written proof to LPA by POC due date.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Sheila Santos
LICENSING EVALUATOR NAME:Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2