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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700630
Report Date: 08/06/2024
Date Signed: 08/06/2024 04:23:21 PM

Document Has Been Signed on 08/06/2024 04:23 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:L.P. NUNEZ CARE FACILITY #3FACILITY NUMBER:
342700630
ADMINISTRATOR/
DIRECTOR:		NUNEZ, LIONELFACILITY TYPE:
735
ADDRESS:8528 BIRCH CREST CTTELEPHONE:
(916) 647-9670
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 4DATE:
08/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Lionel NunezTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced on 8/6/24 at 3:55pm and met with Averey Mata, Caregiver and Lionel Nunez, Administrator stating the purpose of the visit. Avery Mata was given permission to sign this report.

This visit is to cite deficiencies as noted during a Title 17 Monitoring Review conducted on 5/31/24 by Alta California Regional Center (ACRC). 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 to complete but has not completed.

During this visit, Administrator informed LPA that S1 no longer employed at this facility.

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 with Averey Mata and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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 08/06/2024 04:23 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 08/06/2024 at 04:01 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2024
Section Cited
CCR
80064(a)(3)

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Administrator - Qualifications and Duties
The administrator shall have the following qualifications:(3) Knowledge of and ability to comply with applicable law and regulation.
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 POC Cleared prior to today’s visit. Correction was submitted to Alta California Regional Center(ACRC).
Additionally, S1 is no longer employed at this facility.
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This requirement is not met as evidenced by: Based on documentation provided, 1 staff did not complete DSP year 1 before 1 year of hire. Interviews 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:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


LIC809 (FAS) - (06/04)
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