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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881164
Report Date: 01/25/2024
Date Signed: 01/25/2024 12:54:22 PM

Document Has Been Signed on 01/25/2024 12:54 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:RUBIO HOMEFACILITY NUMBER:
331881164
ADMINISTRATOR:RODRIGUEZ, SHAYLAFACILITY TYPE:
735
ADDRESS:51800 AVENIDA RUBIOTELEPHONE:
(760) 972-4194
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY: 4CENSUS: 3DATE:
01/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:House Manager, Vincent OrtizTIME COMPLETED:
01:00 PM
NARRATIVE
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On 1/25/2024, Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit for a separate unrelated matter. This report documents deficiencies found during the visit. LPA met with House Manager, Vincent Ortiz who was informed of the purpose of the visit.

During the visit, LPA conducted a walk through of the facility, interview and records reviews. LPA found (2) staff files where not available for review during the visit. Plan of correction was created with staff and deficiency was reviewed with them. No other health or safety issues were noted during the time of the visit.

An exit interview was conducted with House Manager, Vincent Ortiz where this report, deficiency page and appeal rights reviewed and provided to them.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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 01/25/2024 12:54 PM - It Cannot Be Edited


Created By: Janira Arreola On 01/25/2024 at 12:21 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: RUBIO HOME
FACILITY NUMBER: 331881164

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
80066(c)

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(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...This requirment was not met as evidenced by:
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The staff agreed to send a scanned copy of staff training, criminal record clearance and contact information by the POC due date for the (2) staff.
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Based on record review and interview (2) staff files were not avaible during the visit for audit and review. This poses a potential health, saftey 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:Rikesha Stamps
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


LIC809 (FAS) - (06/04)
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