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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424625
Report Date: 11/03/2022
Date Signed: 11/03/2022 03:41:35 PM

Document Has Been Signed on 11/03/2022 03:41 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
RIVERSIDE, CA 92507
FACILITY NAME:CHICAGO HOUSE, THEFACILITY NUMBER:
336424625
ADMINISTRATOR:STANGEL, DEBORAHFACILITY TYPE:
735
ADDRESS:15055 CHICAGO AVENUETELEPHONE:
(951) 780-0850
CITY:RIVERSIDESTATE: CAZIP CODE:
92508
CAPACITY: 6CENSUS: 6DATE:
11/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Victor Hayes - Assistant AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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On this date, Licensing Program Analyst (LPA) Crystal Colvin made an unannounced visit to the facility to investigate complaint #18-AS-20221028150306. During today's inspection, LPA Colvin observed that while staff (S1) does have background clearance from Department of Social Services, S1 has not been associated to this facility and needs to have their clearance transferred to reflect employment at this location. Additionally, the form LPA Colvin was provided to show that S1's clearance was requested to be transferred to this location is not the correct form to do so, and is not dated or signed. Through interviews LPA Colvin confirmed that S1 has been working at this location for almost a month. Since S1's clearance has not been transferred to this location and S1 has been working at the facility for approximately one month, LPA Colvin will be citing a deficiency and issuing civil penalties in the maximum amount if $500 ($100 per day x 5 days).

While LPA Colvin was typing the report, Corporate Office for the Licensee sent the Administrator a picture of Guardian to show S1's clearance at the facility. LPA Colvin looked at the picture and observed the association date to be 11/3/22, which is today's date. LPA Colvin informed the Administrator of this and that while it's good that S1 is now associated to the facility (and LPA Colvin did check earlier prior to Corporate's call and S1 was not on the facility roster) that S1 still worked at the facility for a month without clearance transfer, and the deficiency will stand.

Due to observations made by LPA Colvin, the facility was cited and civil penalties are being issued in the amount of $500. An exited interview was conducted where a copy this report, LIC809D, LIC421BG, and appeal rights were provided to Assistant Administrator Victor Hayes.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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 11/03/2022 03:41 PM - It Cannot Be Edited


Created By: Crystal Colvin On 11/03/2022 at 03:16 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: CHICAGO HOUSE, THE
FACILITY NUMBER: 336424625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2022
Section Cited
CCR
80019

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Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance... This requirement was not met as evidenced by:
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Licensee provided LPA Colvin with proof of transferring of S1's clearance (dated today). Licensee to provide LPA Colvin with statement of understanding regarding having all clearances transferred prior to staff working at facility. Due by Plan of Correction date of 11/4/22.
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Based on record review and interview, the Licensee did not comply with the above regulation with one staff. LPA Colvin confirmed that S1 has been working at the facility for one month without having their criminal record clearance transferred. This is an immediate safety risk of all residents.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022


LIC809 (FAS) - (06/04)
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