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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603021
Report Date: 01/07/2025
Date Signed: 01/07/2025 01:50:29 PM

Document Has Been Signed on 01/07/2025 01:50 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FAMILY HOME LLCFACILITY NUMBER:
198603021
ADMINISTRATOR/
DIRECTOR:		VILLALVA, JOEL HFACILITY TYPE:
740
ADDRESS:1629 CALLE CIERVOTELEPHONE:
(626) 354-0265
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 3DATE:
01/07/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:02 PM
MET WITH:Joel Villalva, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:53 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez made initial unannounced visit to investigate a complaint allegation. LPA met with Latai Tuihalamak (Tai) DSP and Administrator Joel Villalva showed up a short time later.

The investigation consisted of LPA interviewing three (3) staff (S#1-S#3) and three (3) residents (R#1-R#3). LPA took tour of facility.

During the course of the investigation, LPA learned that the two staff currently working at facility have not been cleared or associated to facility.

Deficiency cited on 809D, Civil penalties issued. $500 each staff.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/07/2025 01:50 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/07/2025 at 01:06 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAMILY HOME LLC
FACILITY NUMBER: 198603021

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/08/2025
Section Cited
CCR
87355(e)(1)

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Criminal Record Clearance Prior to working ... in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.


This requirement is not met as evidence by:
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Administrator will make sure staff are finger printed and associated to facility prior to working at facility, Due to supervision of resident's concerns, LPA did not ask Administrator to remove the staff from premises immediately. Administrator will associated and clear staff by POC date which 01/08/2025
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S1 and S4 are employed by facility for at least 5 days and have not been cleared and/or associated to facility which poses a health a safety 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
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