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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004063
Report Date: 04/05/2023
Date Signed: 04/06/2023 03:33:05 PM

Document Has Been Signed on 04/06/2023 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:DALE B&C HOMEFACILITY NUMBER:
306004063
ADMINISTRATOR:SOPHEAP THONGFACILITY TYPE:
735
ADDRESS:8562 DAVMOR AVENUETELEPHONE:
(714) 537-8718
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 5DATE:
04/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Sopheap ThongTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit for the purpose of conducting a Case Management evaluation to follow up on a 30-Day eviction notice received on 02/22/2023 and on Unusual Incident report received on 03/08/2023 regarding Client 1 (C1). LPA was granted entry into the facility by Staff Sam Ylerma. Administrator (AD) Sopheap Thong arrived shortly after and reason for the visit was explained.

LPA conducted interview with AD, met with Clients, toured the interior and exterior of facility and reviewed C1's file. During tour of the facility, LPA noted Fire Extinguishers were last serviced on 09/23/2014; and LPA noted Client 2, Client 2's shared room bed (currently vacant) and Client 3's mattresses are worn out and dirty.

Regarding Eviction Notice, CCL received an Eviction Notice on 02/22/2023 stating C1 needs to relocate by 02/17/2023. On 02/27/2023, LPA called AD that the 30-Day eviction notice was denied and could not be served to C1 because CCL received the Eviction Notice on 02/22/2023 and per notice, C1 needed to be relocated by 02/17/2023. AD stated told LPA she understood and would resubmit updated Eviction Notice with correct dates. During today's visit, AD admitted to LPA Martinez she had served C1 the Eviction Notice on 02/17/2023 prior to informing CCL of the Eviction. AD submitted the second Eviction Notice on 03/08/2023, stating C1 is to relocated by 03/17/2023. AD stated C1 was put on a 5150 by CAT Team on 03/12/2023 and was transferred to College Hospital on 03/15/2023 where C1 still remains. LPA Martinez confirmed this by reviewing text between AD and C1's family.
LPA Martinez discussed with Administrator the terms and conditions regarding Eviction procedures to which AD stated she understood.
Based on today's interview and documentation reviewed, facility is being cited. An exit interview was conducted with AD and a copy of this report , LIC809D, and LIC 811- Confidential Names will be sent to email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2023
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 04/06/2023 03:33 PM - It Cannot Be Edited


Created By: Lydia Martinez On 04/05/2023 at 05:15 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: DALE B&C HOME
FACILITY NUMBER: 306004063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2023
Section Cited
CCR
80020(a)

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FIRE CLEARANCE: (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department. This requirement was not met as evidenced by:
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Administrator will have the Fire Extinguishers serviced or purchase new Fire Extinguishers and submit proof to LPA by POC due date of 04/06/2023.
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Based on observation, the Administrator did not ensure the facility’s Fire Extinguisher was serviced annually, (last serviced on 09/23/2014, which poses an immediate health and safety risk to the 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:Armando J Lucero
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/06/2023 03:33 PM - It Cannot Be Edited


Created By: Lydia Martinez On 04/05/2023 at 05:32 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: DALE B&C HOME
FACILITY NUMBER: 306004063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
80072(a)(2)

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Personal Rights - (a)...each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings...This requirement is not met as evidenced by:
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Licensee to provide new mattresses that offer adequate support where needed. LIcensee to provide proof to CCL by the POC due date of 04/14/2023.
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LPA observed Client mattresses that were not in good repair and did not offer adequate support. This poses a potential health and safety risk to clients in care.
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Type B
04/14/2023
Section Cited
CCR85068.5

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Eviction Procedures - states that: "The licensee shall be permitted to evict a client by serving the client with a 30-day written notice to quit." This requirement is not met as evidenced by:
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Licensee to review the regulatory requirements for eviction and self certify understanding of regulation and submit copy to LPA by 04/14/2023.
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Based on records reviewed and interviews conducted, the licensee did not comply with the section cited above in that Licensee serviced C1 with Evicition notice on 2/17/2023 and expected C1 to relocated on 2/17/2023. Even though it was error, Licensee did not reserve C1 with correct
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Eviction Notice.
This poses/posed an immediate health, safety or personal rights risk to persons in care.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023


LIC809 (FAS) - (06/04)
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