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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005554
Report Date: 09/28/2021
Date Signed: 09/28/2021 01:18:43 PM

Document Has Been Signed on 09/28/2021 01:18 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:DEVOTED HEART CARE HOMES LLCFACILITY NUMBER:
306005554
ADMINISTRATOR:KEVIN CLARKFACILITY TYPE:
735
ADDRESS:26665 AVENIDA SHONTOTELEPHONE:
(818) 384-9331
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 4CENSUS: 3DATE:
09/28/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Licensee Kevin Clark TIME COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to conduct a case management. LPA met with Licensee Kevin Clark and stated the purpose of this visit

On June 7, 2021, Community Care Licensing Division (CCLD) Orange Office received a complaint no. 22-AS-20210607162452 filed against this facility. During the course of the investigation, LPA observed that the facility had filed three separate incident reports with Regional Center of Orange County. The three incidents involved Client 1 happened on May 7, 2021, May 18, 2021, and May 19, 2021. Per file review, LPA did not observe that CCLD received any of the above reports from the facility.

For this visit, deficiency was observed, and citation was issued per Title 22, Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with Licensee Clark. LPA discussed the deficiency, citation, and appeal rights. Copies of this report, 809 D (Deficiency), appeal rights, and cited regulation were left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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 09/28/2021 01:18 PM - It Cannot Be Edited


Created By: Albert Marin On 09/28/2021 at 12:37 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: DEVOTED HEART CARE HOMES LLC
FACILITY NUMBER: 306005554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2021
Section Cited
CCR
80061(b)(1)(E)

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80061 Reporting Requirements. ... shall be submitted to the licensing agency within seven days following the occurrence of such event...Any unusual incident ..which threatens the physical or emotional health or safety of any client.This Requirement was not met as evidenced by:
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Licensee stated that facility will submit incident reports to Community Care Licensing Division for all reportable occurence in the facility. Plan of correction reviewed and accepted during the visit. Deficiency corrected during the visit.
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Based on file review, observation and interviews, Facility missed to submit written reports to licensing agency within 7 days following occurence of the incident. Facility submitted written report for 3 separate incidents for Client 1 to Regional Center but not to the licensing agency. This posed potential threat on safety of clients in care.
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LPA provided facility of the cited regulation.

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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:Luz Adams
LICENSING EVALUATOR NAME:Albert Marin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021


LIC809 (FAS) - (06/04)
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