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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700782
Report Date: 07/22/2021
Date Signed: 07/22/2021 12:38:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 5DATE:
07/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:TIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPAs) Wolter and Singh arrived at the facility unannounced on 07/22/2021 to conduct a case management visit. LPAs met with Gladys Gasta and explained the purpose of the visit.

Prior to initiating the case management, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPAs temperatures were taken by facility staff.

Community Care Licensing (CCL) was notified via incident report of potential resident financial abuse on 12/03/2020 against resident (R1). An internal investigation was completed by the facility, and it was determined that staff (S1) had used R1’s credit card to purchase goods online, S1 was terminated and R1 was refunded by the facility. On 02/22/2021 CCL received a SOC 341 from the facility of reported financial abuse against resident (R2), with this information CCL conducted a financial abuse audit surrounding the two incidents.

CCL reviewed R2’s monthly credit card statements, SOC 341, Sacramento Sheriff’s Department police report, R1’s forged check and Elder Options Inc statements. R2 had various fraudulent charges on their Safe Credit Union visa credit card account for a total of $3,065, more than 50% of fraudulent activities occurred in Florida. It was further discovered that in addition to the fraudulent online purchase by S1 using R1’s credit card, that a $2,000 forged check was made out to an individual in Florida with known connections to S1.

It is to be noted that R1 resides at 7117 Main Ave and R2 previously resided there before moving to 7121 Main Ave. While the audit was a result of SOC 341 received for 7121 Main Ave appropriate deficiencies are being cited on 7117 Main Ave (342700783), plans of correction are to apply to staff at both facilities.
Exit interview conducted and copy of report emailed to facility due to printer issues.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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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