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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881204
Report Date: 10/31/2022
Date Signed: 10/31/2022 02:55:58 PM

Document Has Been Signed on 10/31/2022 02:55 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:PITACHE RESIDENTIALFACILITY NUMBER:
361881204
ADMINISTRATOR:WILLIAMS, NATALIEFACILITY TYPE:
735
ADDRESS:18025 PITACHE ST.TELEPHONE:
(909) 671-2812
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 4CENSUS: 3DATE:
10/31/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Maddalena Espinoza, CaregiverTIME COMPLETED:
03:00 PM
NARRATIVE
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On 10/31/2022, at 12:47 p.m., Licensing Program Analyst (LPA) Rayshaun Nickolas made a case management visit after conducting an unrelated visit at the facility. The case management visit is in response to a deficiency cited at the facility. LPA met with caregiver Maddalena Espinoza and explained the purpose of the visit. The Licensee Diana Rojas was called, and the purpose of the visit was discussed with the Licensee over the phone.

LPA observed the front door knob was broken. The door knob was pulled out from the security screen door and the door knobs inner components were exposed. LPA knocked on the door and was greeted by Espinoza. LPA identified herself, and Per Espinoza, "can you come through the garage I cannot open this door".

Based on observations and interviews made during today’s inspection, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted with the Licensee over the phone. The licensee has given the LPA permission to allow the house manager, Edraline Mccraw to sign this report and a copy of this report, LIC 809D, and Appeal Rights were given the house manager.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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 10/31/2022 02:55 PM - It Cannot Be Edited


Created By: Rayshaun Nickolas On 10/31/2022 at 02:26 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: PITACHE RESIDENTIAL
FACILITY NUMBER: 361881204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2022
Section Cited
CCR
80087(a)

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80087 (a) Buildings and Grounds

(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.
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Licensee shall repair broken door knob by the POC due date. Proof of correction shall be submitted to the regional office (RO) by 11/02/2022.

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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: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022


LIC809 (FAS) - (06/04)
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