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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801528
Report Date: 02/08/2023
Date Signed: 02/08/2023 01:36:22 PM


Document Has Been Signed on 02/08/2023 01:36 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:MOM'S PLACE 2FACILITY NUMBER:
565801528
ADMINISTRATOR:LINA BOLOTSKYFACILITY TYPE:
740
ADDRESS:30 LA PATERA CT.TELEPHONE:
(805) 383-6855
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 6DATE:
02/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Laila KulunguTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management visit to address deficiencies observed during an unrelated complaint investigation. Administrator Laila Kulungu was contacted via telephone and arrived at 01:08PM. Entrance interview conducted.

During today's visit, interview revealed that Staff #1 (S1) has been working in the facility since December 2022. LPA reviewed the facility Guardian roster and discovered that S1 does have fingerprint background clearance, but is not associated to this facility.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty issued in the amount of $500. Failure to correct the deficiency may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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 02/08/2023 01:36 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: MOM'S PLACE 2
FACILITY NUMBER: 565801528

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2023
Section Cited

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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...(2) Request a transfer of a criminal record clearance as specified...
This requirement is not met as evidenced by:
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Licensee agreed to associate Staff #1 today. Licensee will send proof of S1's association to LPA by POC due date.
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Based on interview and review of Guardian, Staff #1 has been working in the facility since December 2022, but does not have criminal background clearance for this facility, which poses an immediate safety risk to residents 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
LIC809 (FAS) - (06/04)
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