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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603669
Report Date: 11/22/2022
Date Signed: 11/22/2022 03:11:36 PM

Document Has Been Signed on 11/22/2022 03:11 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HABILITATIVE HOMES RESIDENTIAL CARE FACILITYFACILITY NUMBER:
374603669
ADMINISTRATOR:DAVID LARSONFACILITY TYPE:
735
ADDRESS:11775 WALNUT ROADTELEPHONE:
(619) 270-4484
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 6CENSUS: 6DATE:
11/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH: Licensee/Administrator David LarsonTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kayla Hilario conducted an unannounced Case Management Visit. LPA identified herself and met with Licensee/Administrator David Larson, and discussed the purpose of the visit.

Today's visit is in response a file review conducted by the Department. The Licensee for this facility is Habilitative Homes Residential Care Facility LLC. Per review of the California Secretary of State website, their status shows as "Suspended - FTB."

Larson stated that he was changing tax designation status and there was some confusion about LLC. However, Licensee is willing to bring the LLC status to current.

As of today, 11/22/2022, the California Secretary of State website still shows the LLC's status as "Suspended - FTB," and the Statement of Information was due on 10/31/2022. This deficiency is cited in accordance to the California Code of Regulations, Title 22, Division 6, Chapter 1, and is noted on the attached LIC809-D. No other health or safety issues were observed on this date.

The Licensee was provided a copy of their Appeal Rights (LIC9058 3/22), and their signature on this form, acknowledges receipt of these rights. An exit interview was conducted and a copy of this report was provided to Licensee/Administrator David Larson.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Kayla Hilario
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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 11/22/2022 03:11 PM - It Cannot Be Edited


Created By: Kayla Hilario On 11/22/2022 at 03:07 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: HABILITATIVE HOMES RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 374603669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2022
Section Cited
CCR
80063(a)(1)

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Accountability. The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation. If the licensee is a corporation or an association, the governing body shall be active and functioning in order to ensure
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The Licensee stated he will get the LLC in good standing. Once completed, documentation from the Secretary of State website, showing the Licensee is in good status, will be submitted to CCLD by POC due date: 11/23/2022.
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such accountability. This requirement was not met as evidenced by: Based on records review, the licensee does not have their LLC active and functioning in order to ensure such accountability in its operations to six of six residents in care. This poses an immediate health and safety risk to 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:John Rante
LICENSING EVALUATOR NAME:Kayla Hilario
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022


LIC809 (FAS) - (06/04)
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