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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005345
Report Date: 04/10/2023
Date Signed: 04/10/2023 03:15:26 PM

Document Has Been Signed on 04/10/2023 03:15 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PEER HOME 2FACILITY NUMBER:
347005345
ADMINISTRATOR:MONICA FLOR G BUTAYFACILITY TYPE:
735
ADDRESS:7727 MASTERS STREETTELEPHONE:
(916) 509-9450
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
04/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Monica Butay, Raul CupinoTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio conducted a case management inspection of Peer Home 2. LPA met with Assistant Administrator to ensure the facility is in compliance with applicable statutes and regulations. Assistant Administrator called Administrator Monica Butay to inform of the visit. Licensee Raul joined the visit shortly after.

During the visit, the LPA conducted interviews with staff. Based on interviews, staff receive pay checks bi-weekly, never receive a late pay check, have waived breaks, and are currently not approved to work any overtime. There is not any live-in care staff at the home. LPA reviewed staff files and resident files. The facility was observed to have 3 direct staff on shift.

The LPA conducted a tour of the physical plant and observed the facility to be within compliance with Title 22 regulations. Common areas were clean and free of debris. Resident rooms has necessary furniture and furnishings. The facility had a food supply enough for 7 days of perishables and 2 days of non-perishables.

On 04/05/23, the Regional Office was made aware that the U.S. Department of Labor, Wage & Hour Division, Sacramento District Office, completed an investigation towards the licensee. Findings of the investigation revealed that the licensee did not pay employees in compliance with State and Federal Law.

Based on interviews, file/medication reviews, and observation of the physical plant, it appears the facility is not in compliance with applicable statues and regulations. Deficiencies are being cited on LIC 809 - D. Appeal Rights provided to Licensee Raul Cupino.

An exit interview was held with Administrator and Licensee, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2023
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 04/10/2023 03:15 PM - It Cannot Be Edited


Created By: Christina Valerio On 04/10/2023 at 02:43 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PEER HOME 2
FACILITY NUMBER: 347005345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
Section Cited
CCR
80064(a)(3)

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80064 Administrator - Qualifications and Duties (a)The administrator shall have the following qualifications:(3) Knowledge of and ability to comply with applicable law and regulation. This requirement was not met as evidenced by:

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Licensee stated that he has completed the Solvency Correction with Department of Labor and has paid all the fees. Licensee stated he will provided a written statement acknowledging understanding of applicable laws and regulation to LPA by POC due date.
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Based on records review, the licensee did not ensure to have knowledge of and ability to comply with U.S. Department of Labor Laws and regulations, which 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:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023


LIC809 (FAS) - (06/04)
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