<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004519
Report Date: 12/06/2023
Date Signed: 12/06/2023 04:44:24 PM

Document Has Been Signed on 12/06/2023 04:44 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:PEER HOME #1FACILITY NUMBER:
347004519
ADMINISTRATOR:BUTAY, MONICAFACILITY TYPE:
735
ADDRESS:9560 CASTLECAVE WAYTELEPHONE:
(916) 585-9103
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
12/06/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Raul CupinoTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
A Microsoft Teams meeting was held today 12/6/2023 at 3pm to discuss the Audit findings.
The attendees of the meeting were: Representatives of Community Care Licensing (CCL) Regional Manager Acting Liza King, Licensing Program Manager Stephen Richardson, and, Licensing Program Analyst(s) Victoria Brown, Christina Valero, and Vincent Moleski, Auditor Benjamin Banahene, and Representative(s) of Alta Regional Center: Malgorzata Zaglewska, Christina Lane, Heather Hollingworth, Yvette Beltran, Isabella Vega, Representative of Cupino Corporation, JP Grew Inc., and Peer Homes Inc., Raul Cupino.

Acting Regional Manager Liza King began the meeting by stating the purpose of the meeting and introduction began. Benjamin Banahene, Auditor, then proceeded to review the findings of the Audit Investigation. The items of discussion were:
1. Audit findings
2. Record Keeping

Community Care Licensing (CCL) expectations:
-Review USDA requirements for food
-Keep accurate records of all purchases

As a result of the conversations during the meeting Community Care Licensing was advised from Raul Cupino that the utilities are paid by the facility, but the records are held by the owner and are not in his name. At the time, during the pandemic he was having a personal family crisis. Food receipts were not being kept. As the facility was found to be generating sufficient income to cover the operational costs, additional quarterly monitoring will not be imposed at this time.

[continued on 809-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PEER HOME #1
FACILITY NUMBER: 347004519
VISIT DATE: 12/06/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Licensee agrees to: maintain accurate records to be available for review by CCL upon request.

Based on confirmation from the Administrator the records for the sample month were not provided, as were the food receipts. The preponderance of evidence standards has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates, civil penalties may be assessed. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/06/2023 04:44 PM - It Cannot Be Edited


Created By: Vincent Moleski On 12/06/2023 at 04:22 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: PEER HOME #1
FACILITY NUMBER: 347004519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2023
Section Cited
CCR
80076(a)(1)

1
2
3
4
5
6
7
Food Service "(a) In facilities providing meals to clients, the following shall apply:

(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner."

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee shall write a statement acknowledging the food service regulations and the USDA food plan guidelines and affirming that these regulations will be followed in the future. POC to be submitted by fax by POC due date.
8
9
10
11
12
13
14
Based on record review, food receipts recieved by the department's auditor showed that spending per resident on food during the month of March 2023 was less than it should have been based on USDA guidelines, which poses a potential health and safety risk.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/06/2023 04:44 PM - It Cannot Be Edited


Created By: Vincent Moleski On 12/06/2023 at 04:20 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: PEER HOME #1
FACILITY NUMBER: 347004519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2023
Section Cited
CCR
80064(a)(4)

1
2
3
4
5
6
7
Administrator - Qualifications and Duties: "The administrator shall have the following qualifications: Ability to maintain…financial and other records."

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee shall write a statement that all records will be maintained and readily available for review upon request by the Department. POC to be submitted by fax by POC due date.
8
9
10
11
12
13
14
Based on interviews and records review, the administrator did not maintain accurate financial documents pertaining to the operation of the facility which is evidenced by the Department’s auditor requesting utilities bills, and payments, for the sample month of March 2023. The documents were not readily available upon request from the Department.
This posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
12/20/2023
Section Cited
CCR80062(a)(3)(B)

1
2
3
4
5
6
7
Finances: "The licensee shall meet the following financial requirements: Submission of financial reports as required upon the written request of the department or licensing agency. The licensing agency shall have the authority to…request and examine additional information including interim financial statements…"
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee shall write a statement that all records will be maintained and readily available for review upon request by the Department. In addition, the Administrator shall submit a Balance Sheet (LIC403) as requested. POC to be submitted by fax by POC due date.
8
9
10
11
12
13
14
Based on interviews and records review, the administrator did not provide financial bank statements, nor the Balance Sheet (LIC403) for the sample month of March 2023 as requested by the Department’s auditor.
This posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4