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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004561
Report Date: 07/12/2023
Date Signed: 07/12/2023 12:29:26 PM


Document Has Been Signed on 07/12/2023 12:29 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:MAILE ALOHAFACILITY NUMBER:
372004561
ADMINISTRATOR:PEREZ, JOSEPHINE A.FACILITY TYPE:
740
ADDRESS:3636 CHRISTINE STREETTELEPHONE:
(858) 274-0921
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:12CENSUS: 7DATE:
07/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Caregiver Rizalina ZabalaTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced case management visit to issue a deficiency observed during a complaint investigation. The LPA identified himself and explained the purpose of the visit to Caregiver, Rizalina Zabala.

Interviews and review of the Department's Guardian system revealed Staff #1 (S1)'s Background Clearance was not transferred, nor associated to the facility. Additionally, it was revealed S1 had been working and volunteering for approximately half a month, on Mondays, Wednesdays, and Fridays. Based on the evidenced obtained, a deficiency was cited per California Code of Regulations Title 22 and noted on the attached LIC809-D page. An immediate civil penalty of $500 was also assessed on today's date.

An exit interview was conducted with Zabala, to whom a copy of this report, Licensee Appeal Rights (LIC9058), LIC 811, and LIC 421 were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
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 07/12/2023 12:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: MAILE ALOHA
FACILITY NUMBER: 372004561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2023
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or. This requirement was not met as evidenced by:
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Caregiver agreed to remove S1 from the facility until S1's background clearance was transferred and associated to the facility.
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Based on interviews the Licensee did not ensure Staff #1 (S1) had a transferred criminal record clearance which posed a potential health, safety and personal rights risk to 7 of 7 residents 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: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2