<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800577
Report Date: 09/13/2021
Date Signed: 09/13/2021 06:12:41 PM

Document Has Been Signed on 09/13/2021 06:12 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VILLAGE AT SYDNEY CREEK, THEFACILITY NUMBER:
405800577
ADMINISTRATOR:KIRK P KLOTTHORFACILITY TYPE:
740
ADDRESS:1234 LAUREL LANETELEPHONE:
(805) 543-2350
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 84CENSUS: 50DATE:
09/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Kirk Klotthor, AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 11:05 am on 9/13/2021, Licensing Program Analyst (LPA) Chavez arrived at the facility to conduct a 10-day complaint visit. LPA informed Administrator Kirk Klotthor of the reason for the visit. During record review and interviews, LPA determined that the facility has five (5) staff currently employed who do not have fingerprint clearance.

Administrator confirmed that Staff #1 (S1) was hired 8/09/21 and presently works in the facility from 7:00 am to 3:30 pm. S1 had already left for the day. Administrator phoned S1 and informed to not return to work until fingerprint clearance is obtained. Administrator confirmed that Staff #2 (S2) was hired on 8/06/21 and currently working 1:00 pm – 8:30 pm. Administrator stated that Staff #3 (S3) was hired on 8/23/21 and works 8:30 am – 5:00 pm, and that Staff #4 (S4) was hired on 9/01/21 and works 2:30 pm – 11:00 pm. Administrator promptly spoke with S2, S3 and S4, explained the situation, and asked S2, S3, and S4 to leave the premises immediately. S2, S3 and S4 left the facility and will return once they have obtained a criminal background clearance.

Administrator stated that Staff #5 (S5) was hired on 8/10/21 and works 6:30 am – 2:00 pm. S5 was not working today. Administrator spoke with S5, explained the situation, and informed S5 that S5 can return once the fingerprint clearance has been obtained.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Civil penalties assessed in the amount of $2,500.00, $500 for each deficiency.

Exit interview conducted, and today's report and civil penalties were reviewed and emailed to Administrator. Appeal rights issued.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
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 09/13/2021 06:12 PM - It Cannot Be Edited


Created By: Darlene Chavez On 09/13/2021 at 04:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE
FACILITY NUMBER: 405800577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2021
Section Cited
CCR
87355(e)(1)

1
2
3
4
5
6
7
87355(e)(1) 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. The requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator agrees to provide a written declaration stating no staff will work at the facility until a criminal background clearance and association have been obtained. Declaration will be provided via email to LPA no later than end of business day, September 14, 2021.
8
9
10
11
12
13
14
Interviews and record review. S1, S2, S3, S4, and S5 do have a criminal background clearance. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2021


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