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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880555
Report Date: 11/20/2023
Date Signed: 11/20/2023 09:16:37 AM

Document Has Been Signed on 11/20/2023 09:16 AM - 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:JNJ RESIDENTIAL CAREFACILITY NUMBER:
331880555
ADMINISTRATOR:JABONERO, JANICEFACILITY TYPE:
735
ADDRESS:10137 DELCRESTA AVETELEPHONE:
(951) 200-3663
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 4DATE:
11/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Rolando Manaloto, Lead StaffTIME COMPLETED:
09:00 AM
NARRATIVE
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Licensing Program Analyst (LPA), Jesse Gardner, conducted an unannounced visit to the facility to initiate the investigation into complaint #18-AS-20231117150048. LPA identified himself and discussed the purpose of the visit with Lead Staff, Rolando Manaloto.

During the visit, LPA became aware of an uncleared staff member, Efren Badana (UA) who explained that they began working at the facility on 10/28/2023, and works weekends (Saturday, and Sunday) providing care for the clients.

During today’s visit, 1 deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted and a copy of this report along with a copy of the LIC421BG, and LIC809-D were discussed with and provided to Rolando Manaloto, Lead Staff. At the conclusion of the visit, LPA witnessed Badana leave the facility.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
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 11/20/2023 09:16 AM - It Cannot Be Edited


Created By: Jesse Gardner On 11/20/2023 at 08:34 AM
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: JNJ RESIDENTIAL CARE
FACILITY NUMBER: 331880555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2023
Section Cited
CCR
80019(e)(2)

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Criminal Record Clearance: 80019 (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department or.. This requirement was not met as evidenced by:
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Licensee agrees to conduct in-service training of the cited regulation by POC date. Additionally, Licensee agrees to provide LPA UA's clearance when complete.
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Based on observation, interview and record review the licensee did not comply with the section cited above in S1 who did not obtain a clearance prior to working in the facility. This poses an immediate health, safety or personal rights 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:Rikesha Stamps
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023


LIC809 (FAS) - (06/04)
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