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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426029
Report Date: 01/20/2023
Date Signed: 01/20/2023 11:56:14 AM


Document Has Been Signed on 01/20/2023 11:56 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:CALOAKS SENIOR LIVINGFACILITY NUMBER:
336426029
ADMINISTRATOR:AMELIA ALADINFACILITY TYPE:
740
ADDRESS:3891 POLK STREETTELEPHONE:
(951) 689-6162
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:74CENSUS: 56DATE:
01/20/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Amelia AladinTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Melody Brown and Magda Malcore met with Administrator Amelia Aladin at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 01/20/2023 at 10:30 AM AM to initiate a Case Management Office Visit. LPAs Brown and Malcore explained the purpose of the requested Office Visit. The investigation consisted of interviews and a review of pertinent documentation.

On 01/19/2023, LPA Brown received Personnel Report Summary (LIC500) from Administrator Aladin and Staff January 2023 Work Schedule. LPA Brown observed per records review that Staff # 7 (S7) and Staff #8 (S8) was listed in LIC500 with date hire date 02/08/2021 and 12/14/2021 and reported working on January 2023 Staff Schedule. On 01/20/2023, LPA Brown contacted S8 and S8 confirmed working at the facility since 12/14/2021. During the office visit on 01/20/2023, Administrator Aladin confirmed that S7 started working at the facility 02/08/2021 and S8 started working at the facility 12/14/2021. LPA Brown observed per records review that S7 and S8 do not have criminal background clearance per Guardian website and the facility allowed S7 and S8 to work at the facility without criminal background clearance. LPAs Brown and Malcore will issue a deficiency as this pose immediate health, safety and personal rights risk to residents in care.

In addition, LPA Brown observed per records review that Staff # 6 (S6) and Staff #9 (S9) have criminal background clearance but the facility failed to associate S6 and S9 to the facility. During the Office Visit 01/20/2023, Administrator Aladin confirmed that S6 started working at the facility 07/19/2021 and S9 started working at the facility 08/2022. LPAs Brown and Malcore will issue a deficiency as this pose potential heath, safety and personal rights risk to residents in care. Moreover, LPAs Brown and Malcore requested Administrator Aladin to make sure that staffs are associated to the facility or criminal background clearance was transferred to the facility before allowing staff to work at the facility and Administrator Aladin expressed understanding.

Civil penalty was assessed with the amount of $500.00 per individual during the Office Visit for S7 and S8 working at the facility without Criminal Background Clearance. *** Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
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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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: CALOAKS SENIOR LIVING
FACILITY NUMBER: 336426029
VISIT DATE: 01/20/2023
NARRATIVE
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 Also, Civil penalty was assessed with the amount of $500.00 per individual for S6 and S9 due to the facility allowing S6 and S9 to work without transferring or failing to transfer their criminal background clearance.

An exit interview was conducted with Administrator Amelia Aladin where a copy of this report (LIC 809) along with LIC 809D, LIC421BG and Appeal Rights were discussed and provided.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/20/2023 11:56 AM - 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: CALOAKS SENIOR LIVING
FACILITY NUMBER: 336426029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/21/2023
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 Statement of Understanding on CCR 87355(e)(1) to LPA Brown by POC due date.
Licensee stated to remove S7 and S8 from the facility and not allow S7 and S8 to work at the facility until S7 and S8 have a criminal background clearance.
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Based on interview and records review, the Licensee did not comply with the section cited above by allowing S7 and S8 to work at the facility without criminal background clearance which pose immediate health, safety and personal rights risk to residents in care.
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Type B
02/03/2023
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...(2)Request a transfer of a criminal record clearance...This requirement is not met as evidenced by:
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LIcensee stated to submit Signed Statement of Understanding on CCR 87355(e)(2) to LPA Brown by POC due date.
Licensee stated to associate or transfer S6 and S9 to the facility and submit proof to LPA Brown by POC due date
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Based on interview and records review, the Licensee did not comply with the section cited above by allowing S6 and S9 to work at the facility withou or failing to transfer S6 and S9 criminal background clearance which pose potential health, safety and personal rights risks 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: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
LIC809 (FAS) - (06/04)
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