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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880596
Report Date: 10/16/2023
Date Signed: 10/16/2023 12:25:38 PM

Document Has Been Signed on 10/16/2023 12:25 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, 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: 3DATE:
10/16/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Shazet Knownes, House managerTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Rayshaun Nickolas conducted a case management deficiency visit. LPA met with house manager Shazet Knowles at an off site location.

On October 16, 2023, LPA Nickolas' conducted a facility tour in response to complaint control number 56-AS-20231009161458. During the facility tour, LPA Nickolas' discovered that resident #2 (R2) is unable to close their bedroom door because of damage to the door, that was caused by resident #1 (R1). LPA Nickolas observed that the door handle was turned down, and the door was broken around the deadbolt, preventing the door from shutting closed.

Based on observation and interview one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations (CCR).

An exit interview was conducted with Knowles and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2023
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 10/16/2023 12:25 PM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 10/16/2023 at 11:20 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: 10/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement was not met, as evidenced by the following:
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The licensee shall repair R2’s bedroom door. The licensee shall submit proof of this correction by the POC due date of 10/20/2023. LPA Nickolas also informed the house manager that a POC extension can be requested if needed.
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Based on observation and interview, the Licensee did not ensure that the resident #2(R2) was door is good repair, which posed a 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: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023


LIC809 (FAS) - (06/04)
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