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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800085
Report Date: 03/11/2025
Date Signed: 03/11/2025 02:52:30 PM

Document Has Been Signed on 03/11/2025 02:52 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:MCCOY ADULT GROUP HOMEFACILITY NUMBER:
331800085
ADMINISTRATOR/
DIRECTOR:		LACY,TORIFACILITY TYPE:
735
ADDRESS:1113 GARRETSON AVETELEPHONE:
(909) 437-5262
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 6CENSUS: 4DATE:
03/11/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:49 PM
MET WITH:Licensee/Chief Executive Officer Charisse McCoy TIME VISIT/
INSPECTION COMPLETED:
02:55 PM
NARRATIVE
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On 03/11/2025 at 12:49 PM, Licensing Program Analysts (LPAs) Melody Brown and Renese Howell-Small met with Licensee/Chief Executive Officer Charisse McCoy. The investigation consisted of observation, interviews, and a review of pertinent documentation.

During the facility visit today, 03/11/2025, LPAs Brown and Howell-Small noted that the Licensee has not paid their annual fees for the year. These fees were due on the anniversary of the license, in 11/18/2024. The Licensee has additionally accrued a late charge due to the fees being overdue. As of 03/11/2025, the Licensee owes $1.362.00. Deficiency cited. Licensee/Cheif Executive Officer McCoy informed LPAs during the visit that they have a new mailing address and will submit a new change of mailing address to the Department.

An exit interview was conducted where this report (LIC809), LIC809D and Appeal Rights were discussed and provided to Licensee/Chief Executive Officer Charisse McCoy.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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 03/11/2025 02:52 PM - It Cannot Be Edited


Created By: Melody Brown On 03/11/2025 at 02:16 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MCCOY ADULT GROUP HOME
FACILITY NUMBER: 331800085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2025
Section Cited
CCR
80036(a)

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80036 Licensing Fees (a) An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1.

This requirement was not met as evidenced by:
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Licensee paid the required annual fee during the visit today, 03/11/2025. Plan of Correction (POC) cleared.
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Based on record review, the Licensee did not comply with the above regulation with the facility's licensing fees. LPA Brown observed that the Licensee owes $1,362.00. This is a potential safety risk for all clients, as the license may be revoked.
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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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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