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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610087
Report Date: 06/11/2024
Date Signed: 06/11/2024 03:40:34 PM

Document Has Been Signed on 06/11/2024 03:40 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CON CARINO BRAEBURNFACILITY NUMBER:
197610087
ADMINISTRATOR/
DIRECTOR:		MORALES, LINDAFACILITY TYPE:
740
ADDRESS:1744 BRAEBURN RDTELEPHONE:
(626) 485-7756
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 6CENSUS: 6DATE:
06/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Maryuri Yudith Cartin Sanchez-StaffTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Angela Panushkina conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240606110421. LPA met with the House Manager and explained the reason for the visit.

During the visit, LPAs observed that the House Manager was listed on LIC500 Personnel Report, however, the House Manager was not associated with the facility through the Licensing Information System (LIS)


Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D.

Exit interview conducted, appeal rights and copy of report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2024
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 06/11/2024 03:40 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 06/11/2024 at 01:40 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: CON CARINO BRAEBURN
FACILITY NUMBER: 197610087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/13/2024
Section Cited
CCR
87355(e)(1)

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Criminal record clearance: (e) All individuals subject to a criminal record review... (1) Obtain a California clearance or a criminal record exemption as required by the Department.
This requirement is not met as evidenced by:
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Licensee/Administrator agreed to complete House Manager's fingerprints and associate the staff to the facility. Copy of proof will be submitted to LPA by POC date.
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Based on interview and record review, the licensee did not comply with the section cited above by hiring one (1) staff member on 03/02/2021 without fingerprint clearance, which poses an immediate health, safety risks to persons 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


LIC809 (FAS) - (06/04)
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