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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202635
Report Date: 08/24/2022
Date Signed: 09/01/2022 11:34:54 AM


Document Has Been Signed on 09/01/2022 11:34 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/30/2022 04:41 PM

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

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
Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced case management visit at the facility on 08/24/2022. LPA was visiting the facility to follow up on an incident report indicating that a resident at the facility was experiencing burning like sensations. Resident returned to the facility with no updates. Staff on-site at the facility was said to not be fingerprint cleared in follow-up call LPA Christine Delores made to the facility. LPA arrived at the facility at 03:14pm. LPA met with facility staff member (S1).

S1 stated that she was the only person currently working at the facility. LPA asked S1 whether or not they had received fingerprint clearance. S1 stated that they had not, but that they were going to go get it completed tomorrow. LPA checked guardian to determine fingerprint clearance status, which returned no results. Administrator Josephine Arcilla (Admin) arrived at the facility shortly thereafter. LPA informed Admin that no staff members without fingerprint clearance were allowed to be working at the facility, and that S1 would have to leave immediately. Admin stated that she understood and dismissed S1. LPA asked Admin how many days non-fingerprint cleared staff had been working at the facility, Admin confirmed that S1 had been working at the facility in excess of 5 days.

A deficiency was cited during today’s visit, 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.

Exit interview was conducted with Administrator Jesus Arcilla. This report, LIC 809-D, civil penalty, plan of correction, and appeal rights were discussed with Administrator Jesus Arcilla, and copies were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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 09/01/2022 11:35 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/30/2022 04:44 PM

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: LIVE IN SERENITY
FACILITY NUMBER: 445202635

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2022
Section Cited

1
2
3
4
5
6
7
87355 - Criminal Record Clearance - (e) All individuals subject to a criminal record review ... shall prior to working... (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA observation, interview, and record review, the licensee did not comply with the section cited for staff member S1, which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
with the facility prior to working and will submit the plan to LPA by the POC due date.

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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2