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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880596
Report Date: 07/24/2023
Date Signed: 07/24/2023 11:41:34 AM

Document Has Been Signed on 07/24/2023 11:41 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:CAROLINE STREETFACILITY NUMBER:
361880596
ADMINISTRATOR:PATRICIA WOODSFACILITY TYPE:
735
ADDRESS:14461 CAROLINE STTELEPHONE:
(442) 249-1310
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 4DATE:
07/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Shazet Knowles, house managerTIME COMPLETED:
11:48 AM
NARRATIVE
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Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced case management-deficiency visit. LPA Nickolas met with house manager Shazet Knowles and explained the purposed of the visit.

On July 11, 2023, LPA Nickolas’ received an email correspondence regarding Resident #1 (R1). In the correspondence, Staff #1 (S1) indicates “……This is based on LPA Rayshaun Nickolas’ recommendations from 07/10/2023.” This is a false statement. On July 10, 2023, the Licensee asked LPA Nickolas about the regulation process pertaining to evictions. LPA Nickolas provided a response, but not a recommendation as indicated in the correspondence. Based on the information provided, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations (CCR).

An exit interview was conducted, and a copy of this report (LIC 809), LIC 809D, and Appeal Rights were provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
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 07/24/2023 11:41 AM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Rayshaun Nickolas On 07/24/2023 at 08:14 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CAROLINE STREET
FACILITY NUMBER: 361880596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
08/14/2023
Section Cited
CCR
80012(a)

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80012 False Claims (a)
(a) No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This requirement was not met, as further evidenced by:
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S1 agreed to read the cited section of regulations. S1 has also agreed to submit proof that the cited section was read to the Regional Office (RO) by the POC due date.
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Based on the false statement made in an email sent by S1, the Licensee did not ensure that accurate information was provided to everyone included in the email, which posed a potential health, safety, and personal rights violation to persons 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:Karen Clemons
LICENSING EVALUATOR NAME:Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023


LIC809 (FAS) - (06/04)
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