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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334843807
Report Date: 06/23/2022
Date Signed: 06/23/2022 06:36:33 PM

Document Has Been Signed on 06/23/2022 06:36 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:WILD ROOTS HOLISTIC LEARNING CENTERFACILITY NUMBER:
334843807
ADMINISTRATOR:TANYA GAETEFACILITY TYPE:
850
ADDRESS:27655 JEFFERSON AVENUETELEPHONE:
(951) 676-8300
CITY:TEMECULASTATE: CAZIP CODE:
92590
CAPACITY: 76TOTAL ENROLLED CHILDREN: 76CENSUS: DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Program Director Margarita JuarezTIME COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analysts (LPA), Jessica Rubio and James Wilkerson conducted an annual inspection as part of a compliance review. This is a combination childcare center and the other licensed program being: Infant, which was not inspected on this date. LPA met with Program Director Margarita Juarez. A tour of the inside and outside of the facility was granted and the following was observed and/or noted:

· The following items were posted and updated where necessary:
- License
- Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148)
- Parent’s Rights Poster (PUB393)
- Personal Rights (LIC613A)
- Child Car Seat Law
- Menu
· The facility is operating within the limits as stated on the license.
· Ratios are being met during this inspection
· Classrooms are adequately equipped with age and size appropriate furniture and equipment and free of hazards
· There are no weapons present at the facility as stated by Program Director Margarita Juarez
· There are no accessible bodies of water present. LPA’s observed a wading pool in the playground area filled with approximately 1” of water. The area was barricaded and no children were present. LPA’s reminded Program Director that all wading pools or similar product must be emptied immediately after use and stored in an upright position. A citation will be issued.
· Drinking water is provided in the indoor and outdoor activity space by filtered water.
· LPA’s did not observe any medications. There are no medications stored at the facility as stated by Program Director Margarita Juarez.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Jessica M Rubio
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
Document Has Been Signed on 06/23/2022 06:36 PM - It Cannot Be Edited


Created By: Jessica M Rubio On 06/23/2022 at 05:27 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: WILD ROOTS HOLISTIC LEARNING CENTER
FACILITY NUMBER: 334843807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied: Appeal Not Submitted Timely
Type A
Section Cited
CCR
101170(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as two staff (Ref#4 & #9) were present and working and had not received clearances or exemptions which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2022
Plan of Correction
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Program Director Margarita Juarez agrees to have the two staff (Ref#4 & Ref# 9) complete fingerprints by 06/24/2022 and ensure that Ref#4 & #9 do not work in the facility prior to being cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Pauline Beschorner
LICENSING EVALUATOR NAME:Jessica M Rubio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022


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Document Has Been Signed on 06/23/2022 06:36 PM - It Cannot Be Edited


Created By: Jessica M Rubio On 06/23/2022 at 05:27 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: WILD ROOTS HOLISTIC LEARNING CENTER
FACILITY NUMBER: 334843807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observartion, the licensee did not comply with the section cited above as there were cleaning solutions (dish soap) and a cabinet with additional cleaning products accessible to children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2022
Plan of Correction
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Program Director put soap away in the cabinet and locked it while LPA was present.
Type B
Section Cited
CCR
101239(f)(1)
Fixtures, Furniture, Equipment and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers used for storage of solid wastes, including moveable bins, shall have a tightfitting cover that is kept on; shall be in good repair; and shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation there was one trash can with food waste in it and no lid which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2022
Plan of Correction
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Program Director agreed to replace the trash can lid and send proof to LPA by plan of correction die date.
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Jessica M Rubio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022


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Page: 3 of 10
Document Has Been Signed on 06/23/2022 06:36 PM - It Cannot Be Edited


Created By: Jessica M Rubio On 06/23/2022 at 05:27 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: WILD ROOTS HOLISTIC LEARNING CENTER
FACILITY NUMBER: 334843807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238.5(a)(1)
Wading Pools
(a) Notwithstanding the requirements of Section 101238(e), fencing is not required for inflatable or other portable plastic wading pools with sides low enough for children using the pool(s) to step out unassisted. (1)These pools shall be emptied after each use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPA's observed a kiddie pool in the playground area. There was approximately an inch or less of water left in the pool which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2022
Plan of Correction
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Program Director had the pool completely emptied while LPA's were still present.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, three staff (Ref #4, 5, 9) were missing immunizations. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Program Director agreed to submit copies of proof of immunizations to LPA by plan of correction due date.
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Jessica M Rubio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022


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Document Has Been Signed on 06/23/2022 06:36 PM - It Cannot Be Edited


Created By: Jessica M Rubio On 06/23/2022 at 05:27 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: WILD ROOTS HOLISTIC LEARNING CENTER
FACILITY NUMBER: 334843807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review nine out of ten staff files reviewed were missing or had expired Mandated Reporter training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Program Director agreed to submit proof of updated Mandated Rpoerter training to LPA by plan of correction due date.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review four staff (Ref# 4, 5, 7, 9) did not have health screenings on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Program Director agreed to submit proof of health screenings to LPA by plan of correction due date.
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Jessica M Rubio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022


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Document Has Been Signed on 06/23/2022 06:36 PM - It Cannot Be Edited


Created By: Jessica M Rubio On 06/23/2022 at 05:27 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: WILD ROOTS HOLISTIC LEARNING CENTER
FACILITY NUMBER: 334843807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview one staff (Ref #4) was missing a file. File was not present in facility for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Program Director will send the staff file to LPA by plan of correction due date and ensure the file remains on premises.
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review ione child (Ref# 8) was observed to be missing a physicians report from their records including whether risks are present for TB which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Program Director agreed to submit a medical assessment for child (Ref #8) by plan of correction due date.
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Jessica M Rubio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 06/23/2022 06:36 PM - It Cannot Be Edited


Created By: Jessica M Rubio On 06/23/2022 at 05:27 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: WILD ROOTS HOLISTIC LEARNING CENTER
FACILITY NUMBER: 334843807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220.1(a)
Immunizations
(a) Prior to admission to a child care center, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, commencing with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review one child (C1) was observed to not have immunizations on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Program Director will submit Child (Ref#8) immunization records to LPA by plan of correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Pauline Beschorner
LICENSING EVALUATOR NAME:Jessica M Rubio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: WILD ROOTS HOLISTIC LEARNING CENTER
FACILITY NUMBER: 334843807
VISIT DATE: 06/23/2022
NARRATIVE
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· Hazardous items were not stored where inaccessible to children. LPA’s observed dish soap on a sink in the Rosemary classroom. Program Director stated it is usually kept in the cabinet near the sink, however the cabinet was also unlocked and had other cleaning solutions inside of it. A citation will be issued.
· All floors were observed to be clean and safe
· Bathrooms were observed to be safe, sanitary and in operating condition
· Playgrounds are enclosed by appropriate fences and free of hazards
· Outdoor activity areas are supplied with age and size appropriate equipment in good condition
· Food preparation area is clean, free of litter and rubbish and free of rodents and other vermin
· Food is stored appropriately and protected from contamination
· LPA’s also observed a trashcan with food waste in the Hazel classroom with no lid. A citation will be issued.
· Sign in/Sign out records were not reviewed as facility uses electronic sign in/sign out.
· Disaster drills are conducted at least every six months – last drill conducted on 5/13/2022.

A review of staff and children's records were conducted as part of this evaluation.
· Ten children’s files were reviewed. One out of ten children’s records were found to be incomplete during this inspection. One child (Ref#8) was missing a medical assessment and immunization's. A citation will be issued.

· Staff records review indicates that all staff present meet minimum qualifications for the position for which they were hired. There was no proof of Directors Administration classes.
· A staff member is present with current Pediatric CPR/First Aid which expires on 2/19/2024
· Opening and closing staff member’s CPR/First Aid expires on 2/19/2024
· Director completed Health and Safety Training on Fall 2015.
· A review of staff records on this date indicated that not all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Two out of nine staff (Ref#4 & #9) did not have fingerprint clearance. A citation will be issued and civil penalties will be assessed.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Jessica M Rubio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: WILD ROOTS HOLISTIC LEARNING CENTER
FACILITY NUMBER: 334843807
VISIT DATE: 06/23/2022
NARRATIVE
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LPA’s reviewed nine staff records. LPA’s observed the following:
Three staff (Ref #4, 5, 9) missing immunizations.
Nine out of ten staff files reviewed were missing or had expired Mandated Reporter training.
Four staff (Ref# 4, 5, 7, 9) did not have health screenings on file.
One staff (Ref #4) was missing a file. File was not present in facility for review.
Citations will be issued.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The following items were discussed with the Director during inspection:


· Menus shall be posted at least one week in advance in a place visible by the child’s authorized representative, dated and kept on file for 30 days, and made available upon request.
· The areas around or under high climbing equipment, swings, slides, and similar equipment shall be cushioned with material that absorbs a fall
· The Licensee was informed of their reporting requirements and provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov
The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations858@dss.ca.gov

LPA discussed the safe sleep regulations with Program Director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Program Director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Assistant Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Jessica M Rubio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: WILD ROOTS HOLISTIC LEARNING CENTER
FACILITY NUMBER: 334843807
VISIT DATE: 06/23/2022
NARRATIVE
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On-line Licensing forms & regulations for a Child Care Center can be obtained on the Department’s website: www.ccld.ca.gov. Additionally, there is a link to “Receive Important Updates” located on the right side of the page, immediately above Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.
The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

A civil penalty has been assessed during this inspection, payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. You will receive an invoice in the mail. Do not send money until you receive your invoice. Do not send cash.

The Program Director was asked to update the following documents, if applicable, and submit to licensing within 30 days:
1. LIC 500 Personnel Report
2. LIC 610 Emergency & Disaster Plan
3. Parent Handbook/ Program Curriculum/Admission policies and procedures/ fee schedule (only if changes have been made or file copy is more than 2 years old)
4. LIC 309 Administrative Organization (only if changes have been made or file copy is more than 2 years old)
5. LIC 308 Designation of Administrative Responsibility (only if changes have been made& current designation is on file)

The facility is being cited for several Title 22 Regulations. See LIC 809-D for deficiencies.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.
The Notice of Site Visit and Type A Deficiencies from today’s visit must be posted for 30 days. Failure to keep these posted for the entire 30 days will result in an immediate $100 civil penalty for each. An exit interview was conducted, appeal rights were discussed and given to the Program Director Margarita Juarez along with a copy of LIC 9224 (AB 633) and a copy of this report was provided to the Program Director on this date.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Jessica M Rubio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
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