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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700630
Report Date: 10/25/2023
Date Signed: 10/25/2023 11:02:32 AM

Document Has Been Signed on 10/25/2023 11:02 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:L.P. NUNEZ CARE FACILITY #3FACILITY NUMBER:
342700630
ADMINISTRATOR:NUNEZ, LIONELFACILITY TYPE:
735
ADDRESS:8528 BIRCH CREST CTTELEPHONE:
(916) 647-9670
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 3DATE:
10/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Lionel NunezTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/25/23 at 8:45am and met with Averey Mata, Caregiver and Lionel Nunez, Administrator stating the purpose of the visit.

This visit is to cite deficiencies as noted during a Title 17 Monitoring Review. LPA was made aware that the staff had not completed the required training for Direct Support Professional (DSP). The training for staff #1 (S1) had a 12 month window but staff finished 1 month later outside of that window.

LPA observed documentation that the facility has complied with the correction plan by the stated deadlines of 10/11/23 and 10/20/23.

Based on LPAs observations and interview with Administrator the preponderance of evidence standards has been met.

Per California Code of Regulations, Title 22 Division 6, Chapter 6, deficiencies are being cited during this visit.

If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

Exit interview held, Appeal Rights discussed, Copy of report given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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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Document Has Been Signed on 10/25/2023 11:02 AM - It Cannot Be Edited


Created By: Victoria Brown On 10/25/2023 at 09:29 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: L.P. NUNEZ CARE FACILITY #3
FACILITY NUMBER: 342700630

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2023
Section Cited
CCR
80064(a)(7)

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Administrator - Qualifications and Duties
The administrator shall have the following qualifications:Ability to recruit, employ, train, and evaluate qualified staff, and to terminate employment of staff, if applicable to the facility.
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Licensee has submitted proof that additional training was provided to S1.

POC Cleared prior to today’s visit
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This requirement is not met as evidenced by: Based on documentation and interviews which confirmed the correction has been completed. This violation poses a potential health and safety 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:Stephen Richardson
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023


LIC809 (FAS) - (06/04)
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