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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880815
Report Date: 02/22/2023
Date Signed: 02/22/2023 01:46:24 PM


Document Has Been Signed on 02/22/2023 01:46 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:A TENDER TOUCH SENIOR LIVING LLCFACILITY NUMBER:
331880815
ADMINISTRATOR:MOJICA, FLORENCE AFACILITY TYPE:
740
ADDRESS:1651 ROSE AVENUETELEPHONE:
(310) 592-5338
CITY:BEAUMONTSTATE: CAZIP CODE:
92223
CAPACITY:6CENSUS: 3DATE:
02/22/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Licensee/Administrator Monica FlorenceTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Florence Mojica at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 02/22/2023 at 12:20 PM PM to initiate a Case Management Office Visit. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of interviews and a review of pertinent documentation.

LPA Brown reviewed documents and interviewed staffs and it indicated that Staff #4 (S4) started working at the facility 08/01/2021 without criminal background clearance. LPA Brown reviewed Guardian website and it indicated that S4 was granted criminal background clearance last 09/07/2022. LPA Brown will issue a citation for this issue as this pose immediate health, safety and personal rights risk to resident in care.

Civil penalty was assessed with the amount of $500.00 during the Office Visit for allowing S4 to work at the facility without Criminal Background Clearance.

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Licensee/Administrator Florence Mojica.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
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 02/22/2023 01:46 PM - It Cannot Be Edited

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
, CA 92507


FACILITY NAME: A TENDER TOUCH SENIOR LIVING LLC
FACILITY NUMBER: 331880815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2023
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working...(1) Obtain a California clearance... This requirement is not met as evidenced by:
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Licensee stated to submit Signed Statemanet of Understanding on CCR 87355(e)(1) to LPA Brown by POC due date.
Licensee confirmed S4 was granted criminal background clearance last 09/07/2022. POC cleared.
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Based on interview and records review, the Licensee did not comply with the section cited above by allowing Staff #4 (S4) to work at the facility without criminal background clearance since 08/01/2021 which pose immediate health, safety and personal rights risk to resident 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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
LIC809 (FAS) - (06/04)
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