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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003757
Report Date: 06/15/2022
Date Signed: 06/15/2022 11:20:17 AM

Document Has Been Signed on 06/15/2022 11:20 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MILLS CARE HOMEFACILITY NUMBER:
306003757
ADMINISTRATOR:RAFAEL TORRESFACILITY TYPE:
735
ADDRESS:9737 MILLS AVENUETELEPHONE:
(562) 945-6416
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY: 4CENSUS: 3DATE:
06/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Jacqueline Mikin, Assistant AdministratorTIME COMPLETED:
11:25 AM
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) Galarza made an unannounced visit to investigate complaint control #: 28-AS-20220613145720. LPA discussed the purpose of the visit with Assistant Administrator Jacqueline Mikin.

File review of staff files was conducted. Staff (S1) began working at the facility on May 6, 2022 and is cleared, but not associated; which poses an immediate health and safety risk to persons in care.

A deficiency has been cited. See LIC 809D. Civil penalty was assessed.

Exit interview was held with Assistant Administrator. A copy of this report and appeal rights were provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2022
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 06/15/2022 11:20 AM - It Cannot Be Edited


Created By: Noemi Galarza On 06/15/2022 at 10:53 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MILLS CARE HOME
FACILITY NUMBER: 306003757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2022
Section Cited
CCR
80019(f)(1)

1
2
3
4
5
6
7
Criminal Record Clearance. A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from TrustLine to a state licensed facility by providing the following documents to the Department: A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02).
1
2
3
4
5
6
7
Licensee shall complete a criminal record transfer request for staff (S1) by tomorrow.

Submit proof of correction to LPA.
8
9
10
11
12
13
14
This requirement was not met evidenced by:
Based on record review, staff (S1) began working at the facility on May 6, 2022, and has not been associated through Guardian system; which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022


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