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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002587
Report Date: 03/06/2024
Date Signed: 03/06/2024 11:12:20 AM

Document Has Been Signed on 03/06/2024 11:12 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VILLA SANTIAGOFACILITY NUMBER:
306002587
ADMINISTRATOR:CONSUELO M. RODRIGUEZFACILITY TYPE:
735
ADDRESS:817 E. 20TH ST.TELEPHONE:
(714) 542-4126
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY: 6CENSUS: 4DATE:
03/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Connie RodriguezTIME COMPLETED:
08:37 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with the required annual visit.

LPA arrived at the facility at 8:23 AM and was met outside by Client 1 (C1). The client stated there was no staff present as staff had left to drop their child off at school. The client indicated that sometimes the staff leave while the client waits for program to pick the client up. LPA rang the doorbell to which there was no answer. LPA contacted Licensee/ Administrator Connie Rodriguez by telephone and advised of the situation. Licensee arrived to the facility at 8:37 AM and granted LPA entry. Facility staff arrived shortly thereafter.




Based on the observations made during today’s visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to Licensee.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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 03/06/2024 11:12 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 03/06/2024 at 09:11 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: VILLA SANTIAGO
FACILITY NUMBER: 306002587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2024
Section Cited
CCR
80078(a)

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The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not being met as evidenced by:
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Licensee to forward a written plan to LPA outlying provisions for staff to always be present when there are clients present. Licensee to forward by POC due date,
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Based on observation and interview, Licensee failed to ensure care and supervision was being provided. LPA arrived at the facility and there are no staff present and one client present. This poses an immediate health and safety risk to clients in care. CIVIL PENALTY ASSESSED
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
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