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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700782
Report Date: 03/03/2021
Date Signed: 03/03/2021 03:52:39 PM

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:7121 MAIN, LLCFACILITY NUMBER:
342700782
ADMINISTRATOR:COLEMAN, ROBERTFACILITY TYPE:
740
ADDRESS:7121 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 6DATE:
03/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:House Manager, Gladys GastaTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 03/03/2021 to conduct a case management visit. LPA's temperature was taken prior to entry into the facility and LPA was wearing a mask and cleared prior to going into the field. LPA met with staff, Gladys Gasta during today's visit.

LPA came to follow-up on a incident regarding suspected financial abuse against a resident (R1) and to conduct an interview with R1, during LPA's visit R1 was away from the facility at a doctors appointment. LPA reviewed R1's file and observed R1's 602 dated 02/14/2020 states R1 cannot leave the facility unassisted. LPA discovered during visit that the facility had contacted a Lyft for R1 but R1 went to their doctors appointment by themselves.

As a result of today's visit a deficiency is cited on the attached LIC 809-D.

Exit interview conducted, appeal rights provided, and copy of report was emailed to licensee.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021
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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: 7121 MAIN, LLC
FACILITY NUMBER: 342700782
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2021
Section Cited

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ยง1569.312 Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidenced by:
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documentation review and interview. The licensee did not ensure the general safety and well-being of R1 while they were being monitored by the facility. R1's 602 states they are unable to leave the facility unassisted, R1 left the facility unassisted on 03/03/2021. This poses an immediate 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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2021
LIC809 (FAS) - (06/04)
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