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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600546
Report Date: 04/09/2024
Date Signed: 04/09/2024 04:13:40 PM

Document Has Been Signed on 04/09/2024 04:13 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:CAL-CRIS LODGEFACILITY NUMBER:
374600546
ADMINISTRATOR/
DIRECTOR:		GLADYS BELTRANFACILITY TYPE:
735
ADDRESS:8944 EMERALD GROVE AVENUETELEPHONE:
(619) 390-8501
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 10CENSUS: 10DATE:
04/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Julita RenojoTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Adrian Mangina conducted a case management-Deficiencies visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Caregiver, Julita Renojo.
LPA was at the facility for another matter and observed that resident Maria Theresa Renojo, a volunteer caregiver has lived in the home since 2014. Ms. Renojo is fingerprint cleared but not associated to the facility as required.

LPA explained the citation and civil penalties for violation of Title 22, Division 6, Article 3, Section 80019(e)(3) Criminal Record Clearance to Caregiver Julita Renojo.

An exit interview was conducted with Caregiver Julita Renojo who was provided a copy of the Licensee and Appeal Rights (LIC9058 01/16), along with a copy of this report. Ms. Renojo's signature below confirms agreement to receipt of documents.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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 04/09/2024 04:13 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 04/09/2024 at 12:26 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CAL-CRIS LODGE
FACILITY NUMBER: 374600546

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2024
Section Cited
CCR
80019(e)(3)

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Criminal Record Clearance
80019(e) All individuals subject to a criminal record review shall prior to working, residing or volunteering in a licensed facility. Request a transfer of a criminal record clearance as specified in Section 80019(f)... This requirement was not met as evidenced by:
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Facility Representative states will ensure that staff 1 is associated to the facility by POC due date.
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Based on record review the Licensee did not comply with the regulation above as staff #1 has lived in the facility since 2014 and, while fingerprint cleared, they are not associated to the facility as required which poses an immediate safety risk 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Adrian L Mangina
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
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