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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005838
Report Date: 08/24/2022
Date Signed: 08/24/2022 05:41:58 PM


Document Has Been Signed on 08/24/2022 05:41 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:GENTLE CARING HOMEFACILITY NUMBER:
306005838
ADMINISTRATOR:LOURDES LAT, MARIAFACILITY TYPE:
740
ADDRESS:26762 CARLOTA DR.TELEPHONE:
(949) 874-4426
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
08/24/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
04:50 PM
MET WITH:Guillermina Lara-Estrada, caregiver
Maria Lat, Administrator and licensee (via phone)		TIME COMPLETED:
05:45 PM
NARRATIVE
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On 08/24/2022 at 4:50pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct a follow-up inspection focusing on correcting the deficiency observed during the annual inspection visit the previous day. LPA was greeted and granted entry by caregiver Guilermina Lara-Estrada. Administrator Maria Lat was notified by telephone and called again to be notified of the visit's findings. Administrator authorized the caregiver present to sign the present report on her behalf.

When interviewed over the phone, Administrator stated that she had stepped out of the facility for a break but had been at the facility working with the caregiving staff. She stated that the individual missing a background clearance had been sent to get fingerprinted the day before and that she could submit documentation of the fingerprinting.

At approximately 4:55pm, LPA observed caregiver S1 who had been identified as not yet fingerprinted and cleared during the annual inspection visit conducted on 08/23/2022 supervising and assisting a resident during their dinner. Staff member S1 was identified by the other caregiver on staff (S2). A query conducted on Guardian prior to conducting the visit confirmed that staff member S1 was not yet associated to the facility and could not be located in Guardian using her personal information.

Based on the observations made during today’s visit, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations and a civil penalty for a repeat violation is being assessed in the amount of $250. This report was reviewed with facility representative and a copy of this report along with appeal rights was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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 08/24/2022 05:41 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: GENTLE CARING HOME
FACILITY NUMBER: 306005838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2022
Section Cited

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California Code of Regulations Section 87355(e)(1) indicates that: "All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working (...) in a licensed facility: Obtain a California clearance (...) as required by the Department."
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This requirement is not met as evidenced by: During the visit, caregiver S1 was present shadowing caregiver S2. An inquiry in Guardian was not able to locate any background clearance obtained by caregiver.
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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) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2