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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880747
Report Date: 08/02/2023
Date Signed: 08/02/2023 02:01:06 PM

Document Has Been Signed on 08/02/2023 02:01 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:CHIHUAHUA HOMEFACILITY NUMBER:
331880747
ADMINISTRATOR:SHAYLA RODRIGUEZFACILITY TYPE:
735
ADDRESS:77595 CALLE CHIHUAHUATELEPHONE:
(442) 256-4174
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY: 4CENSUS: 2DATE:
08/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Staff, Ixtshelle Sanchez- OrtegaTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the home. LPA found the following deficiencies during the visit. LPA met with Staff, Ixtshelle Sanchez- Ortega and with Licensee John Edgington.

LPA found that Staff #1, Staff #2, and Staff #3 were not associated to the facility roster. LPA was also unable to obtain proof of background clearance for the (3) staff during the visit. Therefore, the facility will be cited with attached civil penalty of $500 per employee.

An exit interview was conducted where this report, LIC809-D and civil penalty assessment were reviewed with staff, Ixtshelle Snachez- Ortega. Licensee was advised over the phone.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
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 08/02/2023 02:01 PM - It Cannot Be Edited


Created By: Janira Arreola On 08/02/2023 at 01:44 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: CHIHUAHUA HOME
FACILITY NUMBER: 331880747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2023
Section Cited
CCR
80019(e)(1)

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(e) All individuals subject to a criminal record review shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption
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Licensee agreed to associate the staff by the POC due date and send the new roster as proof to the LPA.
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LPA found (3) staff on the facility staff scheduled that were not associated and did not have proof of clearance.
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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:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
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