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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330902477
Report Date: 08/22/2023
Date Signed: 08/22/2023 03:02:28 PM

Document Has Been Signed on 08/22/2023 03:02 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:PASS RESOURCE CENTERFACILITY NUMBER:
330902477
ADMINISTRATOR:DUNCAN, PATFACILITY TYPE:
775
ADDRESS:702 EAST 11TH STREETTELEPHONE:
(951) 845-3385
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY: 80CENSUS: 28DATE:
08/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:59 PM
MET WITH:Pat Duncan TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for a complaint and during the investigation LPA Allen was made aware that staff did not meet the required reporting requirements.


During LPA Allen's visit it was determined that the facility staff did not provide community care licensing division with the required document for reporting incidents within the required time frame of seven days following the occurrence of an incident. The interview with Pat Dunca stated that the incident regarding C1 leaving the day program with an unauthorized representative was not reported to community care licensing.
LPA made Pat aware that the facility will be cited regarding reporting requirements and the licensee has agreed to provide training to all staff members on reporting requirements.

A copy of this report LIC809 and LIC809-D was discussed and provided to Pat Dunca at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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 08/22/2023 03:02 PM - It Cannot Be Edited


Created By: Bernadette Allen On 08/22/2023 at 02:27 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: PASS RESOURCE CENTER
FACILITY NUMBER: 330902477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2023
Section Cited
CCR
82061(a)

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82061 (a) REPORTING REQUIREMENTS.
A written report containing the information specified in Section 82061(a)(2) shall be submitted to the licensing agency within seven days following the occurrence of the event.
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The licensee has agreed to provide in service training to staff member by Plan of Correction date (POC) by provideing a written statement of understanding of thecited regulation signed by all staff members.
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This requirement is not met as evidenced by:The licensee stated that the LIC624 was not submitted to CCL regarding C1 being allowed to leave the facility with an unauthorized representative.
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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:Karen Clemons
LICENSING EVALUATOR NAME:Bernadette Allen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
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