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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800108
Report Date: 04/13/2021
Date Signed: 04/13/2021 02:03:40 PM

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 LIVING 2FACILITY NUMBER:
331800108
ADMINISTRATOR:CARRASCO, REBECCAFACILITY TYPE:
740
ADDRESS:470 MEADOWLARK LANETELEPHONE:
(951) 435-7592
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY:6CENSUS: 7DATE:
04/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Licensee/administrator Rebecca CarrascoTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George and Licensing Program Manager (LPM) Joel Esquivel conducted an unannounced visit to conduct a health and safety check. LPA met with Licensee/Administrator Rebecca Carrasco. A tour of the facility was conducted and the facility was observed to be over capacity, as there was 1 additional resident in care. Resident #3 (R3) whom had moved into the facility on April 1, 2021.

Licensee/administrator was informed that since there was a vacant room at the sister facility that a resident needed to be relocated today, with taking the proper steps such as notifying the responsible party and include the duration of the relocation. Resident # 4 (R4) was relocated while LPA and LPM were present.

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, LIC811-confidential names list and appeal rights were provided to Licensee/Administrator 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 2
FACILITY NUMBER: 331800108
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2021
Section Cited

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80028 Capacity Determination
(b) The number of persons for whom the facility is licensed to provide care and supervision shall be determined on the basis of the application review by the licensing agency, which shall take into consideration the following:

(2) The licensee's/administrator's ability to comply with applicable law and regulation.

Based on interviews, observations and record review the licensee did not comply with the staying within the capacity approved for. This poses an immediate health and safety risks to persons 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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