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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604258
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:08:44 PM


Document Has Been Signed on 09/14/2023 03:08 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ALDINE RESIDENTIAL CAREFACILITY NUMBER:
374604258
ADMINISTRATOR:ADAYA, GERALDINEFACILITY TYPE:
740
ADDRESS:794 MARSOPA DRTELEPHONE:
(858) 216-5613
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY:6CENSUS: 5DATE:
09/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Caregiver - Ariel RemotTIME COMPLETED:
03:19 PM
NARRATIVE
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Licensing Program Analyst(LPA) Sara Martinez conducted an unannounced visit regarding complaint 18-AS-20230905151012. LPA met with and was granted entry by caregiver Ariel Remot who was informed of the purpose of the visit.

LPA conducted a tour of the facility, interviews, and record review regarding the complaint and during interviews with staff and residents, LPA discovered the facility had two caregivers working on-call who were not associated to work at the facility. LPA asked administrator Dhana Remot for Staff One (S1) and Staff Two (S2) files. The facility did not have files for the two caregivers and the administrator have not conducted the background check for the two staff members. The facility did not meet Title 22 regulations regarding criminal record clearance and a civil penalty will be issued.

An exit interview was conducted and a copy of this report, deficiency page LIC809-D, civil penalty, and appeal rights were provided to caregiver Ariel Remot.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
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 09/14/2023 03:08 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ALDINE RESIDENTIAL CARE
FACILITY NUMBER: 374604258

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2023
Section Cited
CCR
87355(e)(1)

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87355 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 California clearance or a criminal record exemption as required by the Department...This requirement is not met as evidenced by:
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Licensee will read Title 22 regulation regarding criminal record clearance and will submit proof of criminal record clearance for two staff members. The staff members will not be allowed to work at the facility until clearance is obtained.
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Based on observation, interviews, and records review, the Licensee did not ensure to obtain a criminal record clearance for two staff members prior to them working at the facility which 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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2