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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006153
Report Date: 04/25/2023
Date Signed: 04/25/2023 02:16:24 PM

Document Has Been Signed on 04/25/2023 02:16 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CARE JANELLAFACILITY NUMBER:
306006153
ADMINISTRATOR:CALANGI, KARMIANFACILITY TYPE:
740
ADDRESS:17072 SAGA DRIVETELEPHONE:
(714) 683-4617
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 1DATE:
04/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:House Manager Virgilio GalangTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted a case management visit to address a deficiency observed during a complaint investigation (complaint control # 22-AS-20230420142620).

During the 10-day visit for the complaint listed above, LPA Haley was touring the facility with staff. Around 11:50AM LPA Haley inspected the garage area and observed a man laying on the couch in the garage. LPA Haley, and both facility staff members were present when the unassociated individual (UI) was observed in the garage sleeping on a couch.

LPA Haley asked the man for his full name, his birthday and how long he's been here at the facility.
The man said he arrived last night and House manager (HM) Virgilio Galang said he was there to "shadow."

HM Galang told the UI to get his ID (passport) and fingerprints.
LPA Haley asked HM Galang for a copy of the passport and fingerprint information, and copies were provided (Passport and LIC9163).

LPA Haley explained to the unassociated individual, HM Galang and Staff 2, the UI is not associated and not allowed to be inside the facility until he's fingerprint cleared and associated to the facility. The individual was asked to leave and escorted out by House Manager Galang.

Deficiencies are being cited under California Code of Regulations, Title 22, Division 6, Chapter 8.
An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
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 04/25/2023 02:16 PM - It Cannot Be Edited


Created By: Jerome Haley On 04/25/2023 at 02:11 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 JANELLA
FACILITY NUMBER: 306006153

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2023
Section Cited
CCR
87411(g)(2)

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Personnel Requirements - General

(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c).
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Licensee/Administrator, and all staff will read and review regulation sections:
87411 - Personnel Requirements
87355 - Criminal Record Clearance
Licensee/Administrator will email LPA Haley a signed statement of understanding that the regulations have been read and understood (signed by all staff). Licensee/Administrator will associate the unidentified individual before they're allowed back into the facility. POC due date: April 27, 2023 at 12 noon.
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This reguirement was not met as evidenced by a unassociated individual present during a visual inspection of the garage are. LPA Haley, the House manager, and Staff 2 observed the unassociated individual in the garage around 11:50AM. This poses an immmediate 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:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023


LIC809 (FAS) - (06/04)
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