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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703604
Report Date: 04/07/2022
Date Signed: 04/07/2022 01:28:58 PM


Document Has Been Signed on 04/07/2022 01:28 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:ORCUTT BOARD AND CARE HOMEFACILITY NUMBER:
421703604
ADMINISTRATOR:ANNIE YAGUEFACILITY TYPE:
740
ADDRESS:263 CRESCENT AVE.TELEPHONE:
(805) 934-2586
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:6CENSUS: 3DATE:
04/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Nelson YagueTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Toan Luong conducted a Case Management - Deficiencies. LPA met with Administrator Nelson Yague and explained the purpose of the report.

LPA interviewed staff and reviewed Guardian, California Department of Social Services criminal clearance record database, on 4/7/2022 and learned staff was working at the facility without a criminal record clearance. LPA interviewed Administrator Nelson Yague and was informed that staff had worked at the facility since 4/5/22 and completed a request for live-scan on 4/4/22. The facility did not receive a criminal record clearance for the staff prior to staff being present at the facility as a caregiver. Administrator removed the staff from the facility pending criminal record clearance. LPA issued citation under Title 22, Division 6 Chapter 8 Article 06. Background Check, Section 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.

Deficiency issued on LIC 809D. A civil penalty was issued. LPA conducted exit interview with administrator and emailed a copy of today's report and appeal rights to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022
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 04/07/2022 01:28 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ORCUTT BOARD AND CARE HOME
FACILITY NUMBER: 421703604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2022
Section Cited

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87355(e)(1) Criminal Record Clearance
(e)...pursuant to Health and Safety Code Section 1569.17(b)...(1) Obtain a California clearance or a criminal record exemption as required by the Department orThis requirement is not met as evidenced by:
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Based on record review and interview, LPA found 1 individual working without a Criminal Record Clearance. The licensee did not comply with the section cited above in 1 counts which poses an immediate health, safety or personal rights risk to persons 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022
LIC809 (FAS) - (06/04)
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