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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604267
Report Date: 09/08/2022
Date Signed: 09/08/2022 04:28:44 PM


Document Has Been Signed on 09/08/2022 04:28 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:CLOISTERS OF THE VALLEY, LLCFACILITY NUMBER:
374604267
ADMINISTRATOR:KELLY, CHANNAFACILITY TYPE:
740
ADDRESS:4171 CAMINO DEL RIO SOUTHTELEPHONE:
(619) 283-2226
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:70CENSUS: 67DATE:
09/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Administratror Channa KellyTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Manager (LPM), John Rante, and Licensing Program Analyst (LPA), Riza Alvarez, conducted an unannounced case management visit. LPM and LPA met with Administrator Channa Kelly and we discussed the purpose of the visit.

The Regional Office was notified of a Default Decision & Order regarding an individual identified as a staff member at the facility (Staff 1 - S1).

The Default Decision & Order specifies that S1 is excluded from any care facility licensed by the Department for the remainder of their life. This was ordered on 09/01/2022, and is set to become effective on 09/12/2022.

LPM and LPA conducted a brief tour of the facility and interacted with staff and residents. All staff who interacted with the LPM and LPA on today's date, have a current criminal record clearance. All residents observed by the LPM and LPA also appeared appropriate for the facility.

During today's visit, it was discovered S1 was hired by the facility and worked from 07/20/2020, to 07/25/2020. The current association type for S1 is listed as "pending," and never should have been allowed to work at the facility without an appropriate criminal record clearance. A civil penalty is being issued today in violation of Title 22 regulations in the amount of $500 on form LIC 421BG.

An exit interview was conducted with Channa Kelly. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to Channa Kelly at the conclusion of the visit.

SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Riza Gloria AlvarezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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 09/08/2022 04:28 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: CLOISTERS OF THE VALLEY, LLC
FACILITY NUMBER: 374604267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/09/2022
Section Cited
CCR
87355(e)(1)

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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: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as
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Licensee will review background check clearance procedures and train all appropriate staff members by close of business on 09/09/2022. Documentation of in-service will be provided to CCLD by POC due date: 09/09/2022.
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evidenced by: Based on interviews, and observations, 1 (S1) out of approximately 40 staff did not have a criminal record clearance, prior to beginning work. This posed 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 RanteTELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Riza Gloria AlvarezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
LIC809 (FAS) - (06/04)
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