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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610008
Report Date: 12/05/2024
Date Signed: 12/05/2024 03:22:44 PM

Document Has Been Signed on 12/05/2024 03:22 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HUMBLE HAVEN RCFE IIFACILITY NUMBER:
197610008
ADMINISTRATOR/
DIRECTOR:		ALAS, NICOLE DE LASFACILITY TYPE:
740
ADDRESS:37801 RUDALL AVE.TELEPHONE:
(707) 688-5606
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 6CENSUS: 5DATE:
12/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Raquel AdrianoTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Spaeth conducted an unannounced visit to investigate complaint #31-AS-20241126153912. Upon arrival, LPA was greeted by two staff members (S1 and S2). LPA observed S1 has fingerprint clearance. However, staff member (S2) has not obtained the fingerprint clearance.

LPA Spaeth spoke to the Administrator at 11:45 am regarding the issue. The Administrator stated they are awaiting the clearance notification from the state. LPA stated S2 must leave the facility. At 12:00 pm, a staff member (S3) arrived who has obtained fingerprint clearance. LPA Spaeth observed S2 left the facility at 12:05 pm.

Based upon LPA's observation, the following deficiency is issued.

Exit interview conducted, appeal rights discussed, and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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 12/05/2024 03:22 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 12/05/2024 at 12:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HUMBLE HAVEN RCFE II
FACILITY NUMBER: 197610008

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2024
Section Cited
CCR
87761(b)

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87761 Penalties(b)…a immediate penalty of $100 …per day for a maximum of five (5) days shall be assessed if any individual required to be fingerprinted …has not obtained a California clearance or a criminal record exemption…
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LPA Spaeth observed the staff member (S2) left the facility.
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This is evidenced by: The Licensee failed to ensure a staff member had obtained a California Clearance or a criminal record exemption. This poses an immediate health and 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:Troy Agard
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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