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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880782
Report Date: 06/29/2022
Date Signed: 06/29/2022 02:21:39 PM

Document Has Been Signed on 06/29/2022 02:21 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
, CA 92507
FACILITY NAME:MIMOSA HIGHPOINTEFACILITY NUMBER:
331880782
ADMINISTRATOR:STEWART, LEONAFACILITY TYPE:
735
ADDRESS:15160 MIMOSA DRTELEPHONE:
(562) 682-0946
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 4CENSUS: 4DATE:
06/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Adegboyega AgbelusiTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst Melody Brown conducted an unannounced visit to the facility 06/29/2022 at 12:45 PM to initiate a Case Management visit. LPA Brown met with Administrator Adegboyega Agbelusi and LPA Brown explained the purpose of today's visit.

During the visit at around 01:15 PM, LPA Brown observed Staff 1 (S1) and Staff 2 (S2) not associated at the facility. Licensee Reuben Stewart was contacted and he confirmed that he will transfer S1 and S2 criminal background clearance in Guardian. LPA Brown informed Administrator Adegboyega Agbelusi that deficiency will be issued as this poses potential health to clients in care. Administrator Agbelusi submitted LIC9182 - Criminal Background Clearance Transfer Request form for Staff 1 and Staff 2 to LPA Brown during the visit.


An exit interview was conducted where this report (LIC809), LIC809D and Appeal Rights were discussed and provided to Licensee/Administrator Adegboyega Agbelusi.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
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 06/29/2022 02:21 PM - It Cannot Be Edited


Created By: Melody Brown On 06/29/2022 at 02:00 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
, CA 92507

FACILITY NAME: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/13/2022
Section Cited
CCR
80019(f)

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80019 Criminal Background Clearance (f) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from TrustLine to a state licensed facility by providing the following documents to the Department ...
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Licensee stated to transfer Staff 1 and Staff 2 criminal background clearance to the facility and submit proof to LPA Brown by POC due date.
Licensee stated to submit Statement of Understanding on CCR 80019(f) and submit proof to LPA Brown by POC due date.
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Based on observation, interview and record review, the Licensee did not comply with the section cited above by not transferring the criiminal background clearance of Staff 1 and Staff 2 at the facility which poses an immediate Health, Safety or Personal Rights risk to residents 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022


LIC809 (FAS) - (06/04)
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