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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880834
Report Date: 05/04/2021
Date Signed: 05/04/2021 05:15:57 PM

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
RIVERSIDE, CA 92507
FACILITY NAME:I AM SENIOR HOME 1FACILITY NUMBER:
361880834
ADMINISTRATOR:METU ALOZIE, CHIOMA VFACILITY TYPE:
740
ADDRESS:13560 COBALT ROADTELEPHONE:
(760) 493-1852
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:6CENSUS: 4DATE:
05/04/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Juliet Aguilar, AdministratorTIME COMPLETED:
05:15 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
Licensing Program Analysts (LPAs) Tricia Danielson and Yolanda Delgado arrived unannounced to the facility to conduct a case management visit pertaining to an incident report submitted by the facility. LPAs met with facility staff Cristina and explained the purpose of the visit. Cristina notified Administator (AD) Juliet Aguilar of LPA's presence in the facility. AD arrived shortly thereafter.
On April 30, 2021, Community Care Licensing (CCL) received a self reported incident from the facility detailing a communication made by Resident #1 (R1) to the Licensee via text. Per the incident report, R1 reported Staff #1 (S1) French kissed her as well as groped Resident #2 (R2). Per incident report, the facility terminated S1 immediately upon notice of the incident. During today's visit, LPAs interviewed AD, R1, R2 and requested copies of pertinent records.
During review of facility's personnel summary report, it was discovered that S1 was not listed as associated to the facility. During interview with AD, AD stated S1 began employment at the facility on 03/10/2021 and was terminated 4/26/2021. AD stated S1 did not have a criminal record clearance while employed at the facility.

The following deficiency was cited per Title 22, Division 6 of the California Code of Regulations. This report, along with appeal rights and a confidential names list, was discussed with AD and a copies were provided.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: I AM SENIOR HOME 1
FACILITY NUMBER: 361880834
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2021
Section Cited

1
2
3
4
5
6
7
Criminal Record Clearance- (e) All individuals subject to a criminal record review...shall prior to working...in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c).
This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Licensee did not ensure S1 obtained a criminal record clearance prior to beginning working at facility. Based on record review and interview, S1 has been working at the facility since 03/10/21. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

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: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2