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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004454
Report Date: 06/06/2024
Date Signed: 06/06/2024 07:45:24 PM


Document Has Been Signed on 06/06/2024 07:45 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:NS CAREFACILITY NUMBER:
306004454
ADMINISTRATOR:NOVAC SOFRONIFACILITY TYPE:
740
ADDRESS:10431 AVENIDA CINCO DE MAYOTELEPHONE:
(714) 599-3531
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
06/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:02 PM
MET WITH:Novac Sofrani, Licensee/AdministratorTIME COMPLETED:
05:33 PM
NARRATIVE
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit in conjunction to delivery of complaint investigation findings for complaint control #22-AS-20240311085256.
LPA Quiroz was granted entry by Caregiver 1 (CG1). L/AD Novac Sofrani arrived shortly after. LPA Quiroz explained the reason for the visit.
During today's visit, LPA Quiroz along with (L/AD) Sofroni conducted a tour of the interior and exterior of facility premises. On or about 4:02pm, while reviewing facility personnel report, LPA Quiroz observed CG1 not associated to the facility. L/AD Sofrani indicated " She just started today. Not able to get her live-scan done yet." CG1 verified today was their first work day at facility. LPA Quiroz requested for CG1 to leave the facility premises due not being background cleared. LPA Quiroz observed CG1 leave facility premises. (See LIC 809-D and Civil Penalty Assessment LIC 421IM).
At 4:25pm, while LPA Quiroz along with L/AD Sofrani conducted tour of facility premises, LPA Quiroz observed three vehicles parked on facility driveway and two vehicles on side walk/street blocking facility driveway. Three of five vehicles were observed to have expired tags and one of five was observed to not be operable. (L/AD) Sofroni indicated "Yeah they still have expired tags, and the 69 Chevy Nova has bad battery. Three of the cars are not permitted to be operated on the public road until tags are renewed." (See LIC 809-D)
At 4:30pm while conducting tour in the garage area, LPA Quiroz observed clutter and not able to walk through the garage area. This was verified with (L/AD) Sofroni who indicated "Yeah, it's still bad. I know I need to clean it. I clean it and then it gets bad again." This poses a potential risk to residents in care

The facility is being cited per Title 22, Division 6 of the California Code of Regulations. Repeated violations and failure to correct was assessed on today's date. (SEE CIVIL PENALTY ASSESSMENT – FAILURE TO CORRECT AND REPEAT VIOLATIONS)

An exit interview was conducted with (L/AD) Sofroni, and a copy of this report, LIC 811-Confidential Names, 809-D pages, LIC 421IM, LIC 421-FC pages and Appeal Rights were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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 3


Document Has Been Signed on 06/06/2024 07:45 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: NS CARE
FACILITY NUMBER: 306004454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2024
Section Cited
CCR
87355(a)

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87355(a) Criminal Record Clearance. (a) The Department shall conduct a criminal record review of all individuals... and shall have the authority to approve or deny... presence in the facility, based upon the results of such review. This requirement was not met as evidenced by: CONT
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LPA Quiroz requested for CG1 to leave premises immediately. L/AD Sofrani indicated he will work and relieve CG1.
Immediate risks reduced.
Immediate civil penalty was assessed.
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CONT...Based on file review and interview, the Facility did no secure criminal background clearance for CG1. CG1 was allowed to work at the facility and have direct contact with the residents without criminal background clearance since 6/6/24 at 8am. CONTINUE...
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This poses immediate threat to safety of the residents in care. (see LIC 421BG)
Type B
06/06/2024
Section Cited
CCR87307(d)(6)

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87307(d)(6) Personal Accommodations and Services: (d)The following space and safety provisions shall apply to all facilities:(6)All outdoor and indoor passageways and stairways shall be kept free of obstruction...At 4:25pm, while conducting tour of CONTINUED
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L/AD Sofrani will remove 3 of 5 vehicles with expired tags from facility driveway by POC due date of 6/10/2024.
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CONT..facility premises, LPA Quiroz observed 3 vehicles parked on facility driveway and 2 vehicles on side walk/street of which 3 of 5 have expired tags and 1 of 5 is not operable. (L/AD) Sofroni indicated "Yeah they still have expired tags, and the 69 Chevy...CONTINUE...
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CONT... Nova has bad battery. Three of the cars are not permitted to be operated on the public road until tags are renewed." This poses a potential risk to residents 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/06/2024 07:45 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: NS CARE
FACILITY NUMBER: 306004454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2024
Section Cited
CCR
87203

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87203: Fire Safety-All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not being met as evidenced by: At 4:30pm while
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(L/AD) Sofroni agreed to have garage cleaned by POC due date of 6/13/2024 and submit proof of correction via pictures email to CCL by POC due date.
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CONT...conducting tour in the garage area, LPA Quiroz observed clutter and not able to walk through the garage area. This was verified with (L/AD) Sofroni who indicated "Yeah, it's still bad. I know need to clean it." This poses a potential risk to residents 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3