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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610333
Report Date: 05/18/2024
Date Signed: 05/19/2024 04:29:01 PM

Document Has Been Signed on 05/19/2024 04:29 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
Lookup Error,
, CA
FACILITY NAME:HUMBLE HAVEN RCFE IVFACILITY NUMBER:
197610333
ADMINISTRATOR/
DIRECTOR:		DE LAS ALAS, NICOLEFACILITY TYPE:
740
ADDRESS:4036 TOURNAMENT DRIVETELEPHONE:
(707) 688-5606
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 6DATE:
05/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:19 AM
MET WITH:Jasmin & Jennifer BihasaTIME VISIT/
INSPECTION COMPLETED:
10:20 AM
NARRATIVE
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On 05/18/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA met with caregiver Jasmin Bihasa and explained the purpose of the visit is in association with a complaint investigation conducted on 05/17/24 and 05/18/24.

During the investigation visit on 05/17/24, LPA Dabuet audited the staff files and identified staff #3 (S3) did not have a Criminal Clearance Background Clearance Transfer. (S3) was not associated at this facility when the facility was approved to operate with a Community Care Licensing (CCL) on 11/01/22. (S3) did not appear in (CCLD) Guardian nor Licensing Information System (LIS536).

The licensee is being cited with Title 22 Criminal Clearance Record Regulations 87355(e)(2).

Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8.

Deficiency is issued and an exit interview is conducted with (Jasmin Bihasa) . A copy of this report, appeal rights, and civil penalty were provided.

*Immediate Civil Penalty*
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2024
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 05/19/2024 04:29 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 05/18/2024 at 09:24 AM
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
,
, CA

FACILITY NAME: HUMBLE HAVEN RCFE IV
FACILITY NUMBER: 197610333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2024
Section Cited
CCR
87355(e)(2)

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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, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)...
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Licensee to ensure that all staff prior to working in the facility obtain a Criminal Background Clearance and Criminal Background Transfer Request and provide proof of correction to CCLD by POC due date. Proof of Correction due date: 05/19/24 to ernand.dabuet@dsss.ca.gov
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This requirement is not met as evidenced by: Based on audit review of records, the licensee did not comply with the section. LPA identified staff #3 did not have a Criminal Clearance Background Clearance Transfer associated at this facility. This violation poses an immediate health, safety or personal rights risk to persons in care.
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*A CIVIL PENALTY IS BEING ISSUED TODAY 05/18/24*

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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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024


LIC809 (FAS) - (06/04)
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