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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423576
Report Date: 01/18/2024
Date Signed: 01/18/2024 10:06:39 AM

Document Has Been Signed on 01/18/2024 10:06 AM - 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:PEACEFUL LIVING #2FACILITY NUMBER:
336423576
ADMINISTRATOR:RUSH, JOEFACILITY TYPE:
735
ADDRESS:1112 PEACEFUL DRIVETELEPHONE:
(951) 531-8134
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY: 6CENSUS: 4DATE:
01/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee/Administrator Lena Rush TIME COMPLETED:
10:15 AM
NARRATIVE
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On 01/18/2024 at 08:30 AM, Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Lena Rush to initiate a Case Management Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

During the facility visit on 01/09/2024, Licensing Program Analyst (LPA) Melody Brown requested a copy of the facility’s Personnel Report (LIC500). On 01/12/2024, LPA Brown requested Licensee/Administrator Rush an updated copy of the facility’s form LIC500 and Licensee/Administrator Rush verbalized understanding. LPA Brown received the updated form LIC500 via email and LPA Brown reviewed document received and cross reference Guardian database and observed that Staff #6 (S6), Staff #8 (S8), Staff #9 (S9), Staff #10 (S10) and Staff #12 (S12) have their background clearance, but they were not associated to the facility as their criminal background clearance were not transferred to the facility. Moreover, LPA Brown observed Staff #7 (S7) does not have criminal background clearance. Staff interview and records review indicated S6 started working at the facility on 04/11/2023, S7 on 07/20/2023, S8 on 12/23/2020, S9 on 12/04/2021, S10 on 09/20/2019 and S12 on 07/19/2023. During the facility visit on 01/18/2024, LPA Brown informed Licensee/Administrator Lena Rush that deficiencies will be issued and Civil Penalties were assessed during the facility visit with the amount of $500.00 per individual and will continue to be assessed of $100.00 per day per citation until corrected for failure to obtain criminal record clearance for S7 and for not transferring S6, S8, S9, S10 and S12 criminal background clearance to the facility.

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

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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 01/18/2024 10:06 AM - It Cannot Be Edited


Created By: Melody Brown On 01/18/2024 at 09:11 AM
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: PEACEFUL LIVING #2
FACILITY NUMBER: 336423576

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/19/2024
Section Cited
CCR
80065(i)(1)

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80065 Personnel Requirements (i) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(1) Obtain a California clearance or a criminal record exemption as required...This requirement is not met as evidenced by:
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Licensee stated to remove S7 in their Personnel Report (LIC500) and Staff Schedule and not to allow S7 to work at the facility until S7 criminal backgraound clearance has been obtained and submit proof to LPA Brown at Plan of Correction (POC) due date.
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Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not obtaining S7 criminal background clearance before allowing S7 to work at the facility which pose immediate health, safety, and personal rights risks to clients in care.
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Type B
01/26/2024
Section Cited
CCR80065(i)(2)

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80065 Personnel Requirements (i) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or This requirement is not met as evidenced by:
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Licensee stated to transfer S6, S8, S9, S10 and S12 criminal background clearance to the facility or associate S6, S8, S9, S10 and S12 to the facility and submit proof to LPA Brown by POC due date.
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Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not transferring S6, S8, S9, S10 and S12 criminal background clearance to the facility before allowing S6, S8, S9, S10 and S12 to work at the facility which pose potential health, safety, and personal rights risks to clients 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: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


LIC809 (FAS) - (06/04)
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