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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800142
Report Date: 05/24/2022
Date Signed: 05/24/2022 02:23:59 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2022 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20220520170534
FACILITY NAME:CASA DE FLORESFACILITY NUMBER:
405800142
ADMINISTRATOR:CORINA SEGUNDOFACILITY TYPE:
741
ADDRESS:1405 TERESA DRIVETELEPHONE:
(805) 772-7372
CITY:MORRO BAYSTATE: CAZIP CODE:
93442
CAPACITY:120CENSUS: 89DATE:
05/24/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Corina Segundo, Administrator TIME COMPLETED:
02:35 PM
ALLEGATION(S):
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RSO who is not a client allegedly resides, is present and/or has contact that may pose a risk to the health and safety of clients in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted an unannounced complaint visit to issue final findings. Investigations Branch (IB) Investigator Munoz conducted this investigation on 5/23/2022.

Based on evidence obtained during the course of this investigation, the Department has Substantiated that an individual who has been convicted of a crime for which registration as a Registered Sex Offender (RSO) is required, is residing at the facility or has presence/contact that may pose a risk to the health and safety of the client(s) in care at a facility licensed by the department. This is a factual determination based on all the facts and circumstances of the case.
Exit interview, deficiency cited on 9099-D, civil penalty assessed, report and appeal rights emailed to Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20220520170534
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA DE FLORES
FACILITY NUMBER: 405800142
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2022
Section Cited
CCR
87355(e)(1)
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Criminal Record Clearance. All individuals subject to a criminal record review...(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance...This requirement was not met as evidenced by:
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Licensee terminated S1 on 5/23/2022. Administrator agrees S1 will no longer have contact with residents and agrees to ensure all staff have background clearance before working.
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Based on interview, record review, the licensee did not comply with the above regulation allowing S1 to work in the facility without obtaining a criminal record clearance, which posed an immediate health and safety risk to residents in care.
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 LPA verified during visit today S1 was not present or working at the facility. POC cleared during visit.

$500 Civil Penalty Assesed
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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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
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