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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708716
Report Date: 05/27/2022
Date Signed: 05/27/2022 01:08:11 PM

Document Has Been Signed on 05/27/2022 01:08 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:VISIONARY CARMEL-BY-THE-SEA ASSISTED LIVINGFACILITY NUMBER:
270708716
ADMINISTRATOR:CONNERS, MARGARET P.FACILITY TYPE:
740
ADDRESS:LINCOLN & 7TH STREETTELEPHONE:
(831) 644-9246
CITY:CARMELSTATE: CAZIP CODE:
93921
CAPACITY: 10CENSUS: 7DATE:
05/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Angelique RobinsonTIME COMPLETED:
01:15 PM
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Licensing Program Analyst arrived unannounced on another matter. LPA met with Angelique Robinson Administrator and explained the purpose of the visit.

During the Department’s complaint investigation, it was determined staff member (S1) was not fingerprint cleared to work in the facility in September 2020. This was confirmed by interviews conducted and Licensing Information Systems records which noted S1 was not fingerprint cleared. Administrator stated that the facility and S1 tried to resolve fingerprint clearance issue but were unable to do so. S1 was removed from the facility staff schedule.

Based on interviews and records review, there is preponderance of evidence to prove the alleged violations did occur, therefore the allegation is SUBSTANTIATED.

See 9099-D for deficiency cited per the California Code of Regulations, Title 22. The Department is assessing an immediate CIVIL Penalty in the amount of $500.00.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
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 05/27/2022 01:08 PM - It Cannot Be Edited


Created By: Marybeth Donovan On 05/27/2022 at 08:43 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: VISIONARY CARMEL-BY-THE-SEA ASSISTED LIVING
FACILITY NUMBER: 270708716

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/30/2022
Section Cited
CCR
87355

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87355 Criminal Record Clearance
dividuals 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 removed S1 from the staff schedule and no longer works at the facility.
Licensee with review the Regulation and on Criminal Record Clearance and submit a statement of understanding and review all current employees and new employee applicants are fingerprint cleared by the POC date.

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This requirement was not met as evidenced by: Based on interviews and records review S1 was not finger print cleared to working in the facilty which poses an immediate risk to Health and Safety of resident in care.
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Immediate Civil Penantly being assessed in the amount of $500.00.

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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:Jackie Jin
LICENSING EVALUATOR NAME:Marybeth Donovan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022


LIC809 (FAS) - (06/04)
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