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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157806077
Report Date: 04/25/2022
Date Signed: 05/09/2022 10:43:00 AM


Document Has Been Signed on 05/09/2022 10:43 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:LA PETITE LOFTFACILITY NUMBER:
157806077
ADMINISTRATOR:CHRISTIE O'NEALFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:4CENSUS: 4DATE:
04/25/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Christie O'Neal, Administrator and Samira Hernandez, Facility ManagerTIME COMPLETED:
05:30 PM
NARRATIVE
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On April 25, 2022, Licensing Program Analysts (LPA) Jean Herring arrived at the facility at approximately 1:10 PM for the purpose of conducting a Case Management - Annual Continuation inspection of the facility. LPA met with Christie O'Neal, Administrator and Samira Hernandez, Facility Manager.

During today's inspection, LPA reviewed client records and interviewed two(2) staff members and one(1) client. Two(2) out of 4 clients are non-verbal and one(1) of the verbal clients was not available at the time of the interview.

Client Records. LPA reviewed four(4) client records. All client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to: Identification and Emergency Information; Admission Agreement; consent forms; needs and services plan and/or Individual Program Plan; medical assessment; TB test; dental, vision, medical, and psychological reports; safeguards for cash resources; personal property and valuables; personal rights forms; and medication administration records. LPA also inspected the clients' medications.

During this inspection, LPA observed the following deficiencies:
- All four(4) client records do not contain signed copies of the facility's policies and procedures regarding the client's removal and/or discharge, discipline and complaints.
- NMD1 and NMD2's age exceptions both expired on 12/31/21.
The facility was cited under California Code of Regulations Section 84070(c)(2), Section 84470(b)(2)(F) and 80024(a).

A signed copy of this report was provided to the facility representative along with LIC 809Ds, LIC811 and Appeal Rights.
SUPERVISOR'S NAME: Tira LoganTELEPHONE: (323) 981-3344
LICENSING EVALUATOR NAME: Jean HerringTELEPHONE: (323) 303-7035
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
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 3


Document Has Been Signed on 05/09/2022 10:43 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, 1000 CORPORATE CNTR DR. #200A
MONTEREY PARK, CA 91754


FACILITY NAME: LA PETITE LOFT
FACILITY NUMBER: 157806077

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
84070(c)(2)
Children's Records
(c) If it is determined that the facility can provide the services necessary to meet the child's needs, the following additional information shall be maintained in the child's record: (2) Signed copies of the facility's policies and procedures regarding the child's removal and/or discharge; discipline; and complaints.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Client records (C1 and C2) do not contain signed copies of the facility's policies and procedures regarding the child's removal and/or discharge, discipline and complaints. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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Facility will ensure that each client's file contain signed copies of the facility's policies and procedures regarding the child's removal and/or discharge, discipline and complaints. Proof of correction will be emailed to LPA by the POC due date.
Type B
Section Cited
ILS
84470(b)(2)(F)
Nonminor Dependents’ Records
(b) The licensee shall maintain a separate, complete, and current record or file in the facility for a nonminor dependent. (2) The following shall be included in the nonminor dependent's record or file: (F) The licensee shall maintain the signed copy of the written removal or discharge policies and procedures and document the removal or discharge of a nonminor dependent from the facility as specified in Section 84468.4, Removal or Discharge Procedures, in the records for the nonminor dependent.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Client records (NMD1 and NMD2) do not contain signed copies of the facility's policies and procedures regarding the child's removal and/or discharge, discipline and complaints. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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Facility will ensure that each NMD's file contain signed copies of the facility's policies and procedures regarding the NMD's removal and/or discharge, discipline and complaints. Proof of correction will be emailed to LPA by the POC due date.

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: Tira LoganTELEPHONE: (323) 981-3344
LICENSING EVALUATOR NAME: Jean HerringTELEPHONE: (323) 303-7035
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/09/2022 10:43 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, 1000 CORPORATE CNTR DR. #200A
MONTEREY PARK, CA 91754


FACILITY NAME: LA PETITE LOFT
FACILITY NUMBER: 157806077

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80024(a)
80024(a)
Unless prior written licensing agency approval is received as specified in subsection (b), all licensees shall maintain continuous compliance with the licensing regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. NMD1 and NMD2's age exceptions both expired on 12/31/21. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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The licensee will submit to the licensing agency a written request for an age exception for NMD1 and NMD2, together with substantiating evidence supporting the request. The request will be submitted to LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tira LoganTELEPHONE: (323) 981-3344
LICENSING EVALUATOR NAME: Jean HerringTELEPHONE: (323) 303-7035
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3