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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006400
Report Date: 02/04/2025
Date Signed: 02/04/2025 04:04:59 PM

Document Has Been Signed on 02/04/2025 04:04 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:MG HEIGHTS IFACILITY NUMBER:
306006400
ADMINISTRATOR/
DIRECTOR:		RICO, CAROLYNEFACILITY TYPE:
740
ADDRESS:10612 LEXINGTON STREETTELEPHONE:
(818) 572-3806
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY: 5CENSUS: 4DATE:
02/04/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Mae BarlahanTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced Case Management inspection in conjunction with investigation into complaint number 22-AS-20250204113631. LPA met with Staff Mae Barlahan and explained the purpose of the inspection.

During the course of the investigation, deficiencies were observed. During interviews, LPA was informed by Individual Felina “Lina” Austria and Administrator (AD) Carolyne “Carol” Rico, one of four residents was hospitalized on January 27, 2024 and continues to be hospitalized. Upon records review, LPA did not observe a written report was submitted to Community Care Licensing (CCL) within seven days of the occurrence; a Deficiency was cited on today’s date.

During interviews, Individual Austria stated they were filling in as AD while AD Rico is on vacation out of the country. During their interview, AD Rico confirmed Individual Austria had been filling in for her since December 8, 2024, when she left for vacation. LPA reviewed a list of Guardian roster for facility and was unable to locate clearance for individual Felina Austria and Individual Felorini Brian, who was also presently working at the facility; a Deficiency was cited on today’s date.

Based on observations made during this inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalty is also being assessed. See the attached LIC421BG. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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 02/04/2025 04:04 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 02/04/2025 at 03:21 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: MG HEIGHTS I
FACILITY NUMBER: 306006400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/05/2025
Section Cited
CCR
87355(e)(1)

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(e) All individuals subject to a criminal record review... 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

This requirement is not met as evidenced by:
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AD stated a criminal record clearance or criminal record exemption will be obtained for both individuals and proof provided to LPA via email by POC date.
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Based on observation and AD interview, the licensee did not comply with the section cited above in two of three individuals presently working at the facility, which poses an immediate health, safety and 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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/04/2025 04:04 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 02/04/2025 at 03:27 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: MG HEIGHTS I
FACILITY NUMBER: 306006400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2025
Section Cited
HSC
87211(a)(1)

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(1) A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events specified in (A) through (D) below...

This requirement is not met as evidenced by:
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Staff Barlahan stated a written report will be submitted to CCL regarding incident and provide LPA with a written plan of action to ensure compliance with regulation via email by POC date.
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Based on observation and record review, the licensee did not comply with the section cited above as reporting requirements are not being met, which poses a potential health, safety and 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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
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