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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005500
Report Date: 03/02/2023
Date Signed: 03/02/2023 02:25:11 PM

Document Has Been Signed on 03/02/2023 02:25 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CARE JULIET 1FACILITY NUMBER:
306005500
ADMINISTRATOR:DEL ROSARIO, LESTERFACILITY TYPE:
740
ADDRESS:479 S WELLINGTON RDTELEPHONE:
(209) 914-1153
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 6CENSUS: 6DATE:
03/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Janella Cervania-Caregiver, Lester A. Del Rosario-AdministratorTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced Case Management visit in conjunction with complaint visit 22-AS-20230123111444. LPA Ramirez was greeted and granted entry into the facility and initially met with Caregiver Janella Cervania and explained the reason for the visit.
Administrator (AD) Lester A. Del Rosario arrived shortly after.

During the course of the complaint investigation, LPA reviewed included the Identification and Emergency Information (LIC601) for six residents in care. Per LIC601 three of six residents are under the age of 60.
The purpose of this Case Management visit was because the facility is retaining more than one person under the age of 60.

Based on today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with AD Del Rosario and a copy was provided as well as Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2023
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 03/02/2023 02:25 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 03/02/2023 at 02:05 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CARE JULIET 1
FACILITY NUMBER: 306005500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2023
Section Cited
CCR
87455(b)(7)

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Acceptance and Retention Limitations
(b) The following persons may be accepted or retained in the facility:
(7) Persons who are under 60 years of age whose needs are compatible with other residents in care, if they require the same amount of care and
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Licensee to submit an Age Exception Letter to LPA or Issue a 30-Day Eviction notice by POC due date.
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supervision as do the other residents in the facility. This requirement is not met as evidence by: facility is retaining more than one person under the age of 60 without an approved Age Exception letter. This poses a potential health and safety risk to residents 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023


LIC809 (FAS) - (06/04)
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