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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601947
Report Date: 06/16/2022
Date Signed: 06/16/2022 01:28:38 PM

Document Has Been Signed on 06/16/2022 01:28 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
RIVERSIDE, CA 92507
FACILITY NAME:NALAS ADULT RESIDENTIAL FACILITIES-CARLTONFACILITY NUMBER:
374601947
ADMINISTRATOR:LANGWORTHY, VERONICAFACILITY TYPE:
735
ADDRESS:2822 CARLTON WAYTELEPHONE:
(760) 451-9879
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 4CENSUS: 4DATE:
06/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mikayla Weckesser, Administrative AssistantTIME COMPLETED:
01:00 PM
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On 6/16/22 Licensing Program Analyst (LPA) Javina George arrived at the facility unannounced for the purpose of a complaint investigation (18-AS-20220614120233).
LPA was greeted and granted entry by Volunteer Maria Murillo, and Christian Umana. Administrator arrived was unavailable to meet with LPA, but was available via telephone. There were not any other associated staff present. An hour after LPAs arrival staff Mikayla Weckesser, Administrative Assistant and Jose Salano, Caregiver arrived at the facility. During today's inspection, LPA George observed the following deficiencies:

LPA George reviewed the copy of the personnel roster obtained from the Guardian system, which revealed that both Maria and Christian are both cleared and associated to the facility however, as volunteers and they reside at the facility. Both Maria and Christian are left unsupervised at the facility. Per the DOJ applicant response both Maria and Christian are identified as adult day Res Rehab volunteers. Per Executive Director, Peyton Crow denied that Maria and Christian were volunteers, and were in fact employees. Additionally, LPA requested a copy of a pay stub, and staff schedule, however they were not available or provided. Deficiency cited.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Mikayla Weckesser.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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 06/16/2022 01:28 PM - It Cannot Be Edited


Created By: Javina George On 06/16/2022 at 01:14 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
RIVERSIDE, CA 92507

FACILITY NAME: NALAS ADULT RESIDENTIAL FACILITIES-CARLTON
FACILITY NUMBER: 374601947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
06/30/2022
Section Cited
CCR
80065(c)

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80065 Personnel Requirements
(c) The licensee shall be permitted to utilize volunteers provided that such volunteers are supervised, and are not included in the facility staff plan. This requirement is not met as evidenced by: the facility left 2 volunteers unsuperivised that were providing care to the clients. This poses a potential health, safety, or personal rights risk to persons in care.
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The licensee will submit a copy of the staff schedule with employees schedule to present with volunteers. Proof is to be submitted by 5pm on the due date indicated.

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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:Joel Esquivel
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


LIC809 (FAS) - (06/04)
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