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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701008
Report Date: 03/09/2022
Date Signed: 03/09/2022 03:06:59 PM


Document Has Been Signed on 03/09/2022 03:06 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:PLACE CALLED HOMEFACILITY NUMBER:
392701008
ADMINISTRATOR:VARGAS, BRANDIFACILITY TYPE:
740
ADDRESS:25820 MAGNOLIA AVETELEPHONE:
(714) 948-0381
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY:11CENSUS: 0DATE:
03/09/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee Nataly MartinezTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) arrived unannounced at the facility on March 9, 2022 at 12:30 p.m. to conduct a Case Management visit.

LPA knocked at the door several times loudly and there was no answer. LPA walked around the exterior of the facility, looked inside windows and there was no residents or staff present. LPA observed furniture inside the facility and medical supplies inside the garage. LPA spoke with Licensee Nataly Martinez by phone and she stated she was closing the facility and all the residents moved out. Licensee stated three residents moved home with their families, 1 passed away, and 4 she re located to her other facilities. Licensee stated she spoke verbally with the 5 residents families she re located to her other facilities "A Loving Place" and 'A Loving Place for Your Parents" and asked them if they wanted to be moved to another one of her facilities. Licensee stated she did not notify Licensing of the residents moving or being relocated. Licensee stated she has a meeting with Licensing tomorrow and planned on informing her LPA during the meeting about the relocating of the residents from 'A Place Called Home.". LPA collected resident records for the 3 residents re located to "A Loving Place"

Licensee was notified during an NCC meeting with Licensing on 01/31/2022 of proper eviction procedures. Licensee was also provided Technical Assistance on 03/01/2022 as well regarding eviction procedures.

The following Deficiencies were cited per Title 22 Regulation an exit interview was conducted with Licensee Nataly Martinez and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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 3


Document Has Been Signed on 03/09/2022 03:06 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: PLACE CALLED HOME
FACILITY NUMBER: 392701008

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2022
Section Cited

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87405(h)(1) Administrator Qualifications and Duties. (h) The administrator shall have the responsibility to:(1) Administer the facility in accordance with these regulations and established policy, program and budget. This requirement is not met as evidenced by Administator is not reporting resident relocations and facility closure to licensing.
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which poses an immediate health, safety, or personal rights risk to residents in care.
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Type A
03/10/2022
Section Cited

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87224(f) Eviction Procedures (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by: Licensee stated she did not notify Licensing of resident relocations which poses an immediate health, safety or personal rights 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/09/2022 03:06 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: PLACE CALLED HOME
FACILITY NUMBER: 392701008

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2022
Section Cited

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87468.2 (a)(20)Additional Personal Rights of Residents in Privately Operated Facilities. (20)To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations and shall comply with all eviction and relocation protections for residents. For purposes of this paragraph, "involuntary" means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident.
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The following requirement has not been met as evidenced by: Licensee initiated transfer of 5 residents to 'A Loving Place" and "A Place Called Home", which poses an immediate health, safety or personal rights 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3