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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800058
Report Date: 04/13/2021
Date Signed: 04/13/2021 11:40:49 AM

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
RIVERSIDE, CA 92507
FACILITY NAME:A B CARING SENIOR LIVINGFACILITY NUMBER:
331800058
ADMINISTRATOR:CARRASCO, REBECCAFACILITY TYPE:
740
ADDRESS:1698 ALBERHILL STREETTELEPHONE:
(951) 928-0004
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY:6CENSUS: 4DATE:
04/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Licensee Rebecca CarrascoTIME COMPLETED:
11:13 AM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George and Licensing Program Manager (LPM) Joel Esquivel arrived at the facility unannounced to conduct health and safety check. LPA and LPM conducted a tour of the interior and exterior of the facility and reviewed resident files. All resident files need to be updated, Licensee was provided with regulation of records to be maintained at the facility- Residential Care Facility for the Elderly.

There was adequate staff to provide for the residents in care. However the two Staff 1 and Staff 2 observed working were not associated to the facility. A deficiency will be cited and civil penalties will be assessed.

Based on today's visit, deficiencies were observed in the areas evaluated and cited according to California Code of Regulations, Title 22, Division 6 and listed on the LIC 809D.

An exit interview was conducted and a copy of this report, 809D, LIC 421BG and appeal rights were provided to Licensee Rebecca Carrasco,
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A B CARING SENIOR LIVING
FACILITY NUMBER: 331800058
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/27/2021
Section Cited

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87355 Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
Based on observation, interviews and record review, the licensee did not ensure a criminal record clearance was obtained fro 2 staff members. which poses an immediate health, safety, and personal rights risk to person in care.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2021
LIC809 (FAS) - (06/04)
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