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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005226
Report Date: 09/28/2023
Date Signed: 09/28/2023 01:57:55 PM


Document Has Been Signed on 09/28/2023 01:57 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:ARBOR PALMS OF ANAHEIMFACILITY NUMBER:
306005226
ADMINISTRATOR:YOUNG PARKFACILITY TYPE:
740
ADDRESS:3411 W BALL RDTELEPHONE:
(714) 821-9660
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:130CENSUS: 108DATE:
09/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Karla Lara Ramirez- Resident Care DirectorTIME COMPLETED:
02:25 PM
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) Jessica Cho continued the visit after observing a deficiency while conducting a complaint investigation in connection to Complaint Control Number: 22-AS-20230919083629.
At 12:32pm upon arrival, LPA contacted Administrator (Admin) Darlene Lindley by telephone (who was not present at the time) and stated the purpose of the visit. LPA was greeted by Resident Care Director (RCD) Karla Lara Ramirez who assisted LPA during the visit.

On today's date, LPA met with Staff #1 (S1) at 12:37pm and verified that S1 was not listed on the Department's Licensing Information System (LIS) Facility Personnel Report Summary and the Guardian Employee Roster. S1 confirmed that today was their first day and acknowledged not completed the background check clearance. S1 also confirmed that they met with the residents today. Facility is not in compliance as per Title 22 Regulation 87355 Criminal Record Clearance, all individuals subject to a criminal record review shall prior to working, residing, or volunteering at a licensed facility obtain a California clearance and request a transfer of a criminal record clearance, therefore the preponderance of evidence standard has been met for S1.

A deficiency is being cited as per Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC809D. An immediate civil penalty is assessed. See the attached LIC421BG.

An exit interview was conducted with Resident Care Director Karla Lara Ramirez, and a copy of this report including the LIC809D, LIC421BG, LIC811, and the appeal rights were emailed to the resident care director at the end of the visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
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 09/28/2023 01:57 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: ARBOR PALMS OF ANAHEIM
FACILITY NUMBER: 306005226

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2023
Section Cited
CCR
87355(e)(1)

1
2
3
4
5
6
7
87355 Criminal Record Clearance (e) "All individuals subject to a criminal record review...(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department..."
1
2
3
4
5
6
7
Licensee to provide S1's proof of clearance and to submit an Acknowlegement of Understanding regarding the said deficiency to LPA via emaill by POC due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on observations and interviews, S1 was not fingerprint cleared prior to working or visitng the facility 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: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2