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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003850
Report Date: 01/20/2023
Date Signed: 01/20/2023 11:54:34 AM


Document Has Been Signed on 01/20/2023 11:54 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:WHISPERING OAKS - WAVERLYFACILITY NUMBER:
306003850
ADMINISTRATOR:IMELDA C. CAROFACILITY TYPE:
740
ADDRESS:14782 WAVERLY LANETELEPHONE:
(714) 931-1945
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:6CENSUS: 5DATE:
01/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Imelda Caro - AdministratorTIME COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Patricia Velazquez and Alvaro Ramirez conducted an unannounced Case Management visit to Whispering Oaks - Waverly. LPAs Velazquez and Ramirez met with Administrator Imelda Caro. During the complaint investigation visit with Complaint Number: 22-AS-20201006154007 LPAs Velazquez and Ramirez observed Staff (S) #1 did not appear on the Facility Personnel Report Summary dated January 15, 2023.

At 10:37 AM LPA Ramirez called the Orange County Regional Office and spoke with staff who confirmed S1 was not associated to Whispering Oaks - Waverly.



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 Imelda Caro 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.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
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 01/20/2023 11:54 AM - 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: WHISPERING OAKS - WAVERLY
FACILITY NUMBER: 306003850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/21/2023
Section Cited

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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
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Licensee to ensure all staff have proper criminal record clearance transfer pursuant to regulation and submit written proof to LPA by POC due date.

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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: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
LIC809 (FAS) - (06/04)
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