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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320051
Report Date: 07/15/2022
Date Signed: 07/15/2022 06:57:16 PM

Document Has Been Signed on 07/15/2022 06:57 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PEPPER TREE ASSISTED LIVINGFACILITY NUMBER:
198320051
ADMINISTRATOR:KLEIN, STEPHANIEFACILITY TYPE:
740
ADDRESS:2353 251ST STREETTELEPHONE:
(424) 250-9786
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 6CENSUS: 5DATE:
07/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Licensee - Stephanie KleinTIME COMPLETED:
12:45 PM
NARRATIVE
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On 07/15/2022, Licensing Program Analyst (LPA) Don Senaha conducted a Case Management visit to check on the health and safety of the residents living at the facility. LPA was met with Licensee Stephanie Klien and explained the purpose of the visit.

LPA toured the physical plant with caregivers Princess Diaz and Miguel Can.

There was a deficiency and civil penalty assessed for fingerprint clearance. See LIC 809-D page.

An exit interview was conducted with Licensee Stephanie Klien a hard copy was provided for signature.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2022
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 07/15/2022 06:57 PM - It Cannot Be Edited


Created By: Don Senaha On 07/15/2022 at 11:07 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PEPPER TREE ASSISTED LIVING
FACILITY NUMBER: 198320051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2022
Section Cited
CCR
87355(e)

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87355 (e) Criminal Record ClearanceAll 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. (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 will adhere to Title 22 Section 87355. Staff (S1-S2) will not return to work until they have obtained a California clearance, or a criminal record exemption as required by the CCLD by POC 07/16/22.
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During the visit conducted on 07/15/22, LPA observed and verified that (S1) Princess Diaz and staff (S2) Miguel Can was employed and worked at this facility prior to obtaining a California clearance or a criminal record exemption as required by the CCLD.
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A civil penalty in the amount of $100.00 was issued for S1. A civil penalty in the amount of $500 was issued for S2.

Citation was cleared during visit 07/15//22.

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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022


LIC809 (FAS) - (06/04)
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