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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202754
Report Date: 10/12/2023
Date Signed: 10/12/2023 11:24:53 AM


Document Has Been Signed on 10/12/2023 11:24 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:PRIMAVERA GARDENSFACILITY NUMBER:
435202754
ADMINISTRATOR:MICHAEL ELSOUSOUFACILITY TYPE:
740
ADDRESS:16095 CHURCH STREETTELEPHONE:
(408) 778-5683
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:20CENSUS: 13DATE:
10/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Lisa LanfordTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – deficiencies visit. LPA met with Resident Care Supervisor, Lisa Lanford.

During visit, the facility had 4 staff members working who are all fingerprint cleared and associated to the facility.

On 09/29/2023, the Department received two letters from the facility requesting a Criminal Record Exemption for staff (S1) and (S2). Licensing Program Manager (LPM) Romeo Manzano called and spoke with staff (S3) who states S1 had started working in the facility on-call for the past 6 months. The review of records shows S1’s criminal background clearance was pending, therefore, S1 was not fingerprint cleared to be working facilities.

Based on interview, S1 is no longer employed at the facility. S3 states, S1 was hired in February 2023 and worked at least once to twice a week. On 09/29/2023, S1 was immediately released from work for not obtaining a fingerprint clearance from the Department.

LPA obtained S1's Guardian information, hire date, and facility's LIC500 via email from S3.

A deficiency was cited per California Code of Regulations, Title 22. See LIC 809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S1) working at the facility without fingerprint clearance. Please see LIC-421BG. This report was reviewed with Resident Care Supervisor, Lisa Lanford and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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 10/12/2023 11:24 AM - 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: PRIMAVERA GARDENS
FACILITY NUMBER: 435202754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2023
Section Cited
CCR
87355(e)(1)

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(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 or ... This requirement is not met as evidenced by:
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Licensee immediately released S1 from work. Licensee will review section 87355 and submit a statement of understanding to LPA Dolores via email by POC due date.
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Based on interview, record review and observation the licensee did not ensure staff (S1) received a fingerprint clearance from the Department pior to starting work which poses an immediate health, safety, and 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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
LIC809 (FAS) - (06/04)
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