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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 427806810
Report Date: 12/07/2023
Date Signed: 12/07/2023 10:50:24 AM

Document Has Been Signed on 12/07/2023 10:50 AM - 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, 1000 CORPORATE CNTR DR. #200A
MONTEREY PARK, CA 91754
FACILITY NAME:ANGELS FOSTER CARE SUB OFFICEFACILITY NUMBER:
427806810
ADMINISTRATOR:HOLLY CARMODYFACILITY TYPE:
431
ADDRESS:210 E. CLARK AVE. #DTELEPHONE:
(805) 937-8500
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 19CENSUS: 14DATE:
12/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jennifer MillsTIME COMPLETED:
11:30 AM
NARRATIVE
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On December 07, 2023 at 10:30 AM, Licensing Program Analyst (LPA) Juliet Robles made an unannounced visit to the foster family agency (FFA) and met Jennifer Mills, Director of Operations/Supervising Social Worker for the purpose of conducting a case management inspection regarding a special incident report (SIR) that was submitted to Community Care Licensing Department (CCLD) on 11/10/23 about resource mother’s (RM) Driving Under the Influence DUI case and failed to report to FFA (reference Confidential Name Form LIC 811 dated 12/07/23).

It was found that Resource Mother (RM) failed to report a Special Incident Report (SIR) when she got arrested on 10/27/23 while out to dinner with friends. According to the Director, she found out about the incident from an online arrest report notification and contacted RM and gathered more information. RM confirmed the DUI arrest and withheld the information to the FFA and CSW and planned to report the incident on 11/14/23 during a home visit. Per report, RM’s BAC was below the legal limit so her case was dismissed. LPA was provided a copy of an Order of Set Aside or Reinstatement document from Department of Motor Vehicles (DMV).

The incident dated 10/27/23 was reported to the licensing agency on 11/10/23 after the incident occurred. The special incident report (SIR) did not get reported to the licensing agency or Community Care Licensing (CCL) within 24-hour time frame as required and will be cited today.

Based on the above information, a deficiency citation is issued under 88487.6 REPORTING REQUIREMENTS


(a) A Resource Family shall make a report to a foster family agency when any of the following events occur:
(16) A Resource Parent, or an adult who resides in or is regularly present in the home and has a criminal record clearance or exemption, is arrested, or has a subsequent arrest.

An exit interview was conducted where the citation and plan of correction were discussed. Appeals rights were provided and discussed with the FFA Director.

SUPERVISORS NAME: Yan Yeung
LICENSING EVALUATOR NAME: Juliet Robles
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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 12/07/2023 10:50 AM - It Cannot Be Edited


Created By: Juliet Robles On 12/07/2023 at 10:35 AM
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
, 1000 CORPORATE CNTR DR. #200A
MONTEREY PARK, CA 91754

FACILITY NAME: ANGELS FOSTER CARE SUB OFFICE
FACILITY NUMBER: 427806810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2023
Section Cited
ILS
88487.6(a)(16)

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88487.6 REPORTINGREQUIREMENTS
(a) A Resource Family shall make a report to a foster family agency when any of the following events occur:
(16) A Resource Parent, or an adult who resides in or is regularly present in the home and has a criminal record clearance or exemption, is arrested, or has a subsequent arrest. (b) A Resource Family shall make the report specified in subsection (a) to a foster family agency by telephone, e-mail, or fax within 24 hours or by the next business day following the event.
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The Agency will give training on Reporting Requirements to the Resource Parent.
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This requirement is not met as evidenced by:
Based on records reviewed the Resource Mother (RM) failed to report to the Agency that she was arrested on 10/27/23 for Driving Under the Influence (DUI) when going to dinner with friends which poses a potential Health, Safety, or Personal Rights risk to the children 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:Yan Yeung
LICENSING EVALUATOR NAME:Juliet Robles
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
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