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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880551
Report Date: 11/19/2024
Date Signed: 11/19/2024 01:15:49 PM

Document Has Been Signed on 11/19/2024 01:15 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:PG VALLEJO HOME INCFACILITY NUMBER:
331880551
ADMINISTRATOR/
DIRECTOR:		CIRIC, GABRIELAFACILITY TYPE:
735
ADDRESS:3171 VALLEJO STTELEPHONE:
(951) 318-7461
CITY:RIVERSIDESTATE: CAZIP CODE:
92503
CAPACITY: 4CENSUS: 4DATE:
11/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Gabriela CiricTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
NARRATIVE
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This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 18-AS-20210824163321. LPA met with Administrator (AD) Gabriela Ciric and explained the reason for today’s inspection.

During the course of the investigation, LPA inspected the facility, interviewed AD and witnesses, and obtained and reviewed copies of the client roster, staff roster, and Client #1’s Physician’s Report dated September 14, 2021.

Per AD, C1 was admitted to the facility on August 13, 2021. However, C1’s Physician’s Report dated September 14, 2021, indicates that C1 did not have a Physician’s Report completed until about a month after admission.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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 11/19/2024 01:15 PM - It Cannot Be Edited


Created By: Sean Haddad On 11/19/2024 at 01:01 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: PG VALLEJO HOME INC
FACILITY NUMBER: 331880551

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2024
Section Cited
CCR
80069(b)

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80069 Client Medical Assessment … (b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment… This requirement was not met as evidenced by:
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Licensee stated that they will review Section 80069 and submit a statement of understanding to LPA by POC due date.
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Based on interviews and documents, the licensee did not ensure C1 had a medical assessment prior to accepting C1 into care, which poses a potential safety risk 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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
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