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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800154
Report Date: 03/14/2024
Date Signed: 03/14/2024 03:43:58 PM

Document Has Been Signed on 03/14/2024 03:43 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CASA ALISAFACILITY NUMBER:
331800154
ADMINISTRATOR:ALCOCER, PETER KFACILITY TYPE:
735
ADDRESS:15849 ALISA VIEJO COURTTELEPHONE:
(714) 448-0533
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 4DATE:
03/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee, Peter AlcocerTIME COMPLETED:
04:00 PM
NARRATIVE
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On 3/14/2024, Licensing Program Analyst (LPA) Janette Romero made an unannounced case management visit to the facility to address a deficiency observed during LPA's visit at the facility on 3/14/2024 regarding a complaint investigation. LPA met with Licensee, Peter Alcocer who was informed of the purpose of the visit.

During today's visit, there was two (2) clients and two (2) staff present. LPA interviewed Licensee Alcocer, Staff 1 (S1), Staff 2 (S2), Client 1, Client 2, and conducted a record review. S1 reported working in the facility twice per week for approximately one month and a half, cooking and serving meals to the clients. S1 reported they have not submitted their fingerprints for a criminal record review. LPA observed S1 cooking in the kitchen. Licensee reported S1 cooks for the clients and performs light cleaning in the facility. Licensee reported they did not believe S1 required a criminal record clearance. LPA reviewed the facility's personnel report summary which confirmed S1 does not possess a criminal record clearance. Due to S1 being employed in the facility, having regular contact with the clients, and not possessing a criminal record clearance, the facility will cited pursuant to Health and Safety Code 1522(b)(1)(D).

An exit interview was conducted where a copy of this report was reviewed and provided to Licensee Alcocer along with an LIC809-D, LIC421BG, Confidential Names List (LIC811) and Appeal Rights.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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 03/14/2024 03:43 PM - It Cannot Be Edited


Created By: Janette Romero On 03/14/2024 at 03:09 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
RIVERSIDE, CA 92507

FACILITY NAME: CASA ALISA
FACILITY NUMBER: 331800154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2024
Section Cited
HSC
1522(b)(1)(D)

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(b) (1) In addition to the applicant, this section is applicable to criminal record clearances and exemptions for the following persons: (D) Any staff person, volunteer, or employee who has contact with the clients. This requirement was not met as evidenced by:
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Licensee stated they will have Staff 1 (S1) submit to a fingerprint criminal record review and wait for S1 to obtain a criminal record clearance prior to returning to work in the facility.
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Licensee did not comply with the regulation noted above by allowing Staff 1 to work in the facility and have regular contact with the clients prior to obtaining a criminal record clearance from the Department. This poses an immediate safety risk to clients in care.
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During LPA's visit, S1 was escorted out of the facility by Licensee.

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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:Tricia Danielson
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024


LIC809 (FAS) - (06/04)
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