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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603788
Report Date: 11/08/2022
Date Signed: 11/08/2022 04:39:18 PM


Document Has Been Signed on 11/08/2022 04:39 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:LOVING HANDS SENIOR CAREFACILITY NUMBER:
374603788
ADMINISTRATOR:WILDFONG, MARIAFACILITY TYPE:
740
ADDRESS:3245 STAR ACRES DRIVETELEPHONE:
(619) 303-3862
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91978
CAPACITY:6CENSUS: 2DATE:
11/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maria Ibisate Wildfong, AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renita Hall and Interim Assistant Program Administrator (IAPA) Icela Estrada, conducted an unannounced visit to follow up on a complaint investigation. LPA and IAPA were allowed entry by Staff 3, caregiver. LPA and IAPA identified themselves and disclosed the purpose of the visit.

LPA and IAPA identified Staff 3 as not being part of the personnel roster, Upon review of the Department's background clearance system, Staff 1 was not identified in system to have a criminal background clearance to work at a facility. Staff 3 verified that she has not been fingerprinted and has worked at the facility intermittently for approximately 8 months, two to three days a week and serves as a back up caregiver. IAPA and LPA observed S3 providing care to the two residents in care. Staff 3 advised that the Administrator was attending a private family event and was not available. She advised another caregiver was scheduled to relieve her this evening. IAPA and LPA remained in the facility until Administrator arrived at approximately 3:00 PM.

An exit interview was conducted with Administrator. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator and her signature on this report confirms receipt of the Licensee Rights.

SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 11/08/2022 04:39 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: LOVING HANDS SENIOR CARE
FACILITY NUMBER: 374603788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2022
Section Cited

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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: (1) Obtain a CA clearance or a criminal record exemption as required by the Department.
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This requirement was not met as evidenced by: Based on interview, records, and systems review, the licensee did not ensure Staff #1 had a CA criminal record clearance prior to working or volunteering in the licensed facility which posed an immediate safety risk to 2 of 2 residents in care
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Type A
11/08/2022
Section Cited

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 Subsequent violations within a twelve (12) month period will result in a civil penalty of one hundred ($100) per violation per day for a maximum of thirty (30) days.

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This requirement was not met as evidenced by: Based on interview, records, and systems review, the licensee did not ensure Staff #1 had a CA criminal record clearance prior to working or volunteering in the licensed facility which posed an immediate safety risk to 2 of 2 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 RanteTELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2