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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602750
Report Date: 12/20/2021
Date Signed: 12/20/2021 02:33:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/13/2020 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20200713102845
FACILITY NAME:ELMIRA HOME CAREFACILITY NUMBER:
374602750
ADMINISTRATOR:JENKINS, VALERIEFACILITY TYPE:
735
ADDRESS:361 ELMIRA STREETTELEPHONE:
(619) 749-9761
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:4CENSUS: 4DATE:
12/20/2021
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Valerie and Mel Jenkins, Licensee(s)TIME COMPLETED:
09:15 AM
ALLEGATION(S):
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- Staff lack proper criminal background clearance.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to the facility to deliver findings for a complaint investigation regarding the above-mentioned allegation. LPA Lopez identified herself and was granted entry by Jill Raymond, Direct Support Personnel (DSP). LPA stated the purpose of the visit with Valerie Jenkins and Mel Jenkins, Licensee.

The Department’s investigation consisted of but was not limited to record reviews, interviews with staff and an outside source which were pertinent to this investigation.

On 07/13/20 it was alleged that there were staff working at the facility who did not have a criminal background clearance prior to working for the facility. Records review revealed that staff who worked for the facility did not have proper background clearance prior their start date for working at the facility. Staff interviews confirmed that there was at least
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 08-AS-20200713102845
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ELMIRA HOME CARE
FACILITY NUMBER: 374602750
VISIT DATE: 12/20/2021
NARRATIVE
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one staff who did not have proper background clearance completed prior to working for the facility. Interviews with staff and an outside source stated that the facility was in need of additional staffing to replace former staff. Evidence obtained supported the allegation that staff S1 and S2 (see LIC 811 confidential names list) did not have required criminal background clearance prior to employment at the facility.

The Department has investigated the above-mentioned allegation and based upon the evidence obtained during interviews and documentation, it found that there is sufficient evidence to prove that the allegation occurred. Therefore, the allegation is determined to be substantiated.

The report was discussed with Valerie Jenkins, Licensee, plan of correction was reviewed and a copy of this report along with the Applicant/Licensee Rights (LIC9058 01/16) was provided to the Licensee telephone and Mel Jenkins present at the facility and sent via email. An electronic email receipt confirms the documents were received.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20200713102845
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ELMIRA HOME CARE
FACILITY NUMBER: 374602750
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2021
Section Cited
HSC
80019(f)
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80019(f) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, ... This requirement was not met by:
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Licensee stated she will submit clearance transfer paperwork to associate S1 and S2 by 12/29/2021, and verify this to clear POC. Licensee will submit to the Regional Office with a cc to LPA.
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Based on interviews and records review, the licensee did not request transfer of criminal record clearance for staff S1 and S2 prior to work start date. This posed a potential safety risk for three out of four clients 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.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3