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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002482
Report Date: 02/14/2024
Date Signed: 02/14/2024 05:56:28 PM


Document Has Been Signed on 02/14/2024 05:56 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CAREWELL MANORFACILITY NUMBER:
306002482
ADMINISTRATOR:CAROL WILSONFACILITY TYPE:
740
ADDRESS:3330 W. STONYBROOK DRIVETELEPHONE:
(714) 827-8520
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 6DATE:
02/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Carol Wilson- AdministratorTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho continued the visit after observing a deficiency while conducting an investigation in connection to Complaint Control Number: 22-AS-20221004145131. LPA explained the purpose of this Case Management-Deficiencies visit to Administrator Carol Wilson.

While investigating the complaint investigation mentioned above, LPA verified that Staff #1 (S1) was not associated per the Department's Licensing Information System (LIS) Facility Personnel Report Summary and the Guardian Employee Roster printed on today's date. S1 was employed on January 7, 2024. Therefore, the preponderance of evidence standard has been met as the facility did not ensure that S1 was associated as required by the Title 22 Regulations, 87355 Criminal Record Clearance.

A deficiency is being cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC809-D. An immediate civil penalty is being assessed. See the attached LIC421BG.

An exit interview was conducted with Administrator Carol Wilson, and a copy of this report including the LIC809D, LIC421BG, LIC811, and the appeal rights were provided at the end of the visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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 02/14/2024 05:56 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CAREWELL MANOR
FACILITY NUMBER: 306002482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/15/2024
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance "(e) 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: (2) Request a transfer of a criminal record clearance..."
This requirement was not met as evidenced by:
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Administrator to provide proof of association for S1, and to submit an Acknowlegement of Understanding regarding the said deficiency to LPA via emaill by POC due date.
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Based on LPA's observations, interviews, and review of records, S1 was not associated at the time of the visit which poses an immediate Health, Safety, or Personal Rights risk to persons 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: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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