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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005923
Report Date: 02/03/2023
Date Signed: 02/03/2023 03:32:52 PM

Document Has Been Signed on 02/03/2023 03:32 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:BILLY'S HOUSEFACILITY NUMBER:
306005923
ADMINISTRATOR:PERSSON, JACLYNFACILITY TYPE:
735
ADDRESS:367 S GREENGROVE DRIVETELEPHONE:
(714) 831-1330
CITY:ORANGESTATE: CAZIP CODE:
92866
CAPACITY: 4CENSUS: 3DATE:
02/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Karry Vallejo - AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Billy's House. LPA Velazquez was allowed entry into the home and met with Administrator Karry Vallejo. During the complaint investigation visit with complaint number: 22-AS-20220908144115 LPA Velazquez observed Staff Nely Guerrero did not appear on the facility's LIC 500 form which is their staff work schedule and did not appear on the Facility Personnel Report Summary. At 1:47 PM LPA Velazquez proceeded to call the Orange Regional Office and LPA was informed that Staff Nely Guerrero was not associated to Billy's House.



Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 1 and a Civil Penalty was also issued.

An exit interview was conducted with Administrator Karry Vallejo and a copy of this report along with the appeal rights, and LIC 9098 were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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 02/03/2023 03:32 PM - It Cannot Be Edited


Created By: Patricia Velazquez On 02/03/2023 at 03:16 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: BILLY'S HOUSE
FACILITY NUMBER: 306005923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2023
Section Cited
CCR
80019(e)(2)

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Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in
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Licensee to ensure all staff have proper transfer of their criminal record clearance and submit written proof to LPA by POC due date.
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Section 80019(f). This requirement is not met as evidenced by: based on record review & interview the licensee did not obtain a transfer of a criminal clearance for Staff Nely Guerrero. This poses an immediate risk to the health & safety of clients in care. CIVIL PENALTY ASSESSED
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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:Sheila Santos
LICENSING EVALUATOR NAME:Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023


LIC809 (FAS) - (06/04)
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