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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209349
Report Date: 04/09/2024
Date Signed: 04/16/2024 12:24:19 AM


Document Has Been Signed on 04/16/2024 12:24 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:AILE ASSISTED LIVINGFACILITY NUMBER:
547209349
ADMINISTRATOR:CERVANES, ARMANDOFACILITY TYPE:
740
ADDRESS:1542 E. GLENWOOD AVENUETELEPHONE:
(408) 420-7538
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY:6CENSUS: 0DATE:
04/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Armando Cervantes,
Licensee/Administrator		TIME COMPLETED:
04:45 PM
NARRATIVE
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On 04/09/24, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a required 10 day site visit for complaint allegations received. LPA contacted Licensee via telephone and stated the purpose of the visit. Licensee was unable to come to the facility and instructed Staff S1 to open the house and allow LPA's entry. LPA toured the home inside and out with S1 and observed the facility to be empty with no one living inside.

During the course of Records reviews, LPA observed facility's roster of criminal records clearances and found there is no documentation that a criminal record clearance transfer was completed for Staff S1 and Staff S2. A review of personnel records show that 3 out of 3 staff employed at the facility, do not meet the qualifications to substitute as a designee for the Administrator. Administrator is not at the facility 7 days a week. Licensee, Administrator and facility manager are, in fact, the same person.

Based on the information received and in accordance with California Code of Regulations, Title 22, Division 6, deficiencies are being cited on the attached 809-D. This poses an immediate risk to the health, safety and personal rights of residents in care. An immediate civil penalty in the amount of $500 is hereby assessed for Caregiver Background Clearance Transfer.

A copy of this report and appeal rights were sent via email due to Licensee being out of the area. Licensee will send signed copy of report to LPA via email upon receipt. Plans of corrections are cleared due to Licensee surrendering the license and there are no residents in care.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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 04/16/2024 12:24 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: AILE ASSISTED LIVING
FACILITY NUMBER: 547209349

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2024
Section Cited
HSC
1569.618(b)(1)

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ยง1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:(1) Knowledge of the requirements for providing care and supervision appropriate to each resident of the facility.
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Licensee has surrendered licensee. Health and Safety Inspection completed, no residents in facility.
-POC cleared-
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This requirement was not met as evidenced by records review, staff employed at the facility do not meet the qualifications to substitute as a designee for the Administrators. Licensee, Administrator and Manager are all the same person, Armando Cervantes.
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Type A
04/09/2024
Section Cited
CCR87411(g)(2)

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(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:(2) Request a transfer of a criminal record clearance..This requirement was not met as evidenced by:
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Licensee has surrendered licensee.
- POC cleared -
**Immediate Civil Penalty Assessed**
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LPA records review of facility file. There is no documentation that a criminal record clearance transfer was completed for Staff S1 and Staff S3. S1 and S3 have worked over 30 days in the facility. This poses an immediate risk to the health and safety of the residents in care. A immediate civil penalty in the amount of $500 is hereby assessed for Caregiver Background Criminal Clearance Record Transfer
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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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
LIC809 (FAS) - (06/04)
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