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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366410632
Report Date: 08/31/2023
Date Signed: 08/31/2023 10:19:37 AM

Document Has Been Signed on 08/31/2023 10:19 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KHEESA'S FAMILY HOMEFACILITY NUMBER:
366410632
ADMINISTRATOR:THOMAS, D'ANN TFACILITY TYPE:
735
ADDRESS:17269 SAN BERNARDINO AVE.TELEPHONE:
(909) 427-0957
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 6CENSUS: 4DATE:
08/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Laporsha Grant-Facility ManagerTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced case management visit during complaint visit, control number 56-AS-20230622160531. LPA met with Facility Manager Laporsha Grant and explained the reason for the visit.

During today visit, LPA discovered that Staff S1 does not have an approved criminal background clearance to work at the facility. S1 informed LPA that they have been working at the facility for three (3) years.

Based on observations today, one (1) type A deficiency was cited per Title 22, Division 6, of the California Code of Regulations, along with a $500-dollar civil penalty.



An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Manager Laporsha Grant, along with a copy of LIC809D, LIC811, LIC421BG, and the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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
Document Has Been Signed on 08/31/2023 10:19 AM - It Cannot Be Edited


Created By: Ryan Gardner On 08/31/2023 at 09:12 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
RIVERSIDE, CA 92507

FACILITY NAME: KHEESA'S FAMILY HOME
FACILITY NUMBER: 366410632

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2023
Section Cited
CCR
80019(e)(1)

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80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department or
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The licensee has agreed to read regulation 80019 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed remove S1 from the facility.
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Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by S1 working at the facility without a criminal background clearance which poses an immediate health, safety, or personal rights risk to persons in care.
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The licensee has agreed to not allow S1 to work at the facility until S1 has an approved criminal background clearance. The POC is due by 9/1/2023.

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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:Efren Malagon
LICENSING EVALUATOR NAME:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
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