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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602263
Report Date: 12/14/2022
Date Signed: 12/14/2022 04:23:51 PM

Document Has Been Signed on 12/14/2022 04:23 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:NP CARE HOMEFACILITY NUMBER:
198602263
ADMINISTRATOR:TATUM, RONICFACILITY TYPE:
740
ADDRESS:3767 VIRGINIA ROADTELEPHONE:
(323) 205-5145
CITY:LOS ANGELESSTATE: CAZIP CODE:
90016
CAPACITY: 6CENSUS: 6DATE:
12/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH: Krystal Perkins, AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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On 12/14/22, Licensing Program Analyst (LPA) Antonia Alvizar conducted a case management inspection visit at this facility. LPA was greeted by Caregiver, Milere Martinez then later Krystal Perkins, Administrator joined and explained the purpose of the visit. LPA was at this facility in conjunction with complaint # 11-AS-20221209162052.

During the visit LPA was made aware the facility failed to adhere to regulations Title 22 Section 87355(e)(1). LPA identified and confirmed staff #1 (S1) worked at this facility from 01/02/22 to 12/14/22 caring for residents without proof of criminal clearance background approval. Krystal, Administrators stated, "S#1 will not return to work until obtained a California Clearance or a Criminal Record Exemption as required by (CCLD) Community Care Licensing Division.

Based on the information gathered, the licensee violated the California Code Regulations (CCR) of Title 22 sections 87355(e)(1) Division 6 Chapter 8.



Citation is issued, civil penalties assessed, and exit interview conducted a copy was provided to Administrator, Krystal Perkins.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2022
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 12/14/2022 04:23 PM - It Cannot Be Edited


Created By: Antonia Alvizar On 12/14/2022 at 03:50 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: NP CARE HOME
FACILITY NUMBER: 198602263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2022
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance: 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:(1)Obtain a California clearance or a criminal record exemption as required by the Department
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Administrator will adhere to title 22 and will ensure that all staff are criminal record clearance reviewed and approved.

The administrator will remove all staff that are not criminal record clearance approval.
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Based on observation and interviews, the Administrator did not comply with the section cited above. The facility did not have approved criminal record clearance for S#1.This violation poses an immediate health, safety or personal rights risk 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:Ulysses Coronel
LICENSING EVALUATOR NAME:Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022


LIC809 (FAS) - (06/04)
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