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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800484
Report Date: 09/09/2021
Date Signed: 09/09/2021 02:16:48 PM

Document Has Been Signed on 09/09/2021 02:16 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
RIVERSIDE, CA 92507
FACILITY NAME:VIA GENOAFACILITY NUMBER:
331800484
ADMINISTRATOR:EDGINGTON, JOHN TFACILITY TYPE:
735
ADDRESS:47018 VIA GENOATELEPHONE:
(760) 262-5957
CITY:INDIOSTATE: CAZIP CODE:
92201
CAPACITY: 4CENSUS: 4DATE:
09/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Paulina Corona - House ManagerTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of investigating a complaint (#18-AS-20210902121126) as well as following up on a recent incident which was reported to Community Care Licensing (CCL) regarding alleged physical abuse of a resident (R1) by a staff member (S1). During today's visit, LPA Colvin conducted interviews and reviewed facility records for R1 and S1. Additional investigation for the incident will be taking place on LPA Colvin's part to determine if action by CCL is appropriate.

Additionally, during today's inspection, LPA Colvin observed that a number of staff (6 total) were not associated to the facility. LPA Colvin reviewed staff files for all unassociated staff to confirm background check clearance and to see if a request for association had been submitted to CCL. Below is what LPA Colvin observed:
  • S1, S2, & S4 are not associated but have active background clearance and transfer request forms in file.

  • S3 is not associated but have active background clearance. No transfer request in file, but Licensee states has and will email to LPA. S3 started this month and has worked 3 days (9/5, 9/6, & 9/7).

  • S5 is not associated and needs an exemption approval to work at the facility. An exemption transfer request form was present in S5's file, but has not been approved by the Department. Title 22 Regulations state that if a staff member requires an exemption, it must be granted prior to them being able to work in the facility. S5 has been working in the facility for at least two years without the approved transfer of S5's exemption. Deficiency cited and civil penalties assessed for $100 per day for a maximum of 5 days. Total assessed for S5 is $500.

  • S6 is not associated but has a background clearance (labeled as active-not working), which expires soon, as S6 has not been associated to any facility since 2019. Additionally, S6 has been working at the facility since 2020 and there is no transfer request form in S6's file. Deficiency cited and civil penalties assessed for $100 per day for a maximum of 5 days. Total assessed for S6 is $500.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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: VIA GENOA
FACILITY NUMBER: 331800484
VISIT DATE: 09/09/2021
NARRATIVE
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  • S7 is not associated to the facility but has an active background clearance. LPA Colvin observed a transfer request in S7's file, but the form was missing vital information such as S7's clearance identification number. Since the form was missing information necessary to process (and has not been processed as evidenced by S7 not being associated), the form is considered invalid. S7 has been working at the facility since 2018. Deficiency cited and civil penalties assessed for $100 per day for a maximum of 5 days. Total assessed for S7 is $500.


Due to LPA Colvin's observations, deficiencies were cited and civil penalties were assessed in the amount of $1,500 ($500 each for S5, S6, & S7). An exit interview was conducted with House Manager Paulina Corona where a copy of this report, LIC 809D, LIC421BGs, and appeal rights were provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2021 02:16 PM - It Cannot Be Edited


Created By: Crystal Colvin On 09/09/2021 at 01:45 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: VIA GENOA
FACILITY NUMBER: 331800484

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2021
Section Cited
CCR
80019(e)(2)

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Criminal Record Clearance: (e) All individuals ...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f). This requirement was not met by:
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Licensee agrees to submit transfer request in person or via mail to CCL's Riverside Regional Office on Spruce St. prior to S6's & S7's next shift. Licensee may alternatively utilize the Guardian system online for immediate processing. Proof of request to be submitted to LPA Colvin by 9/10/21.
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Based on record review, the Licensee did not comply with the above regulation with 2 staff (S6 & S7). LPA Colvin observed that neither S6 nor S7 had a valid background transfer request in their facility files and were not associated to the facility. This is an immediate health and safety risk for all residents.
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Type A
09/10/2021
Section Cited
CCR800019(e)(3)

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Criminal Record Clearance: (e) All individuals...shall prior to working, residing or volunteering in a licensed facility: (3) Request and be approved for a transfer of a criminal record exemption... This requirement was not met by:
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Licensee agrees to submit exepmtion transfer request to Sacramento. Licensee understands that S5 may not work in the facility until the exemption is approved. Licensee to provide LPA Colvin with Statement of Understanding regarding this requirement, as well as updated staffing schedule without S5 by 9/10/21.
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Based on record review, the Licensee did not comply with the above regulation with 1 staff (S5). LPA Colvin observed that S5 requires an expemtion to work at the facility. No exemption has been approved for S5 for this facility. This is an immediate health and safety risk for all residents.
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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 Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2021


LIC809 (FAS) - (06/04)
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