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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005810
Report Date: 01/12/2022
Date Signed: 01/12/2022 02:41:33 PM

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 FAMILY CARE HOMEFACILITY NUMBER:
306005810
ADMINISTRATOR:PICENO, CASSANDRAFACILITY TYPE:
740
ADDRESS:12041 GILBERT STTELEPHONE:
(714) 949-1351
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 3DATE:
01/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Administrator Claudia OlteanuTIME COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Jerome Haley and Joseph Alejandre made an unannounced case management visit to address unauthorized building construction, identified during the complaint investigation visit for complaint number, 22-AS-20211230093410, see LIC9099 dated 1/10/2022. LPAs met with Administrator (AD) Claudia Olteanu and took a tour of the structure. The new structure is not identified on the facility sketch. The AD reported that the new building has a separate address. LPAs observed the new building does have a separate gas and electric meter. The Agency (CCL) has not verified if the building has a separate address. The electric meter shows an address of 12043 Gilbert St. The new structure does share a common roof and walls with the facility. The facility did not report to the Agency the construction of the new building, and did not provide any facility sketches or plans.
Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8 and the Health and Safety Code.
An exit interview was conducted. A copy of this report along with the appeal rights were provided at the time of this visit.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
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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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: DEVOTED FAMILY CARE HOME
FACILITY NUMBER: 306005810
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/13/2022
Section Cited

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80086 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. This requirement is not being met as evidenced by LPAs observed new building construction that does not match the fire clearance and facility sketch.
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This information was never reported to the Agency (CCL). And was discovered during a complaint visit. This poses an immediate health and safety risk to residents in care.
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Licensee agrees to comply with title 22 in regards to alterations or changes to the facility. Licensee to forward 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: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2022
LIC809 (FAS) - (06/04)
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