<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530128
Report Date: 10/03/2024
Date Signed: 10/03/2024 10:59:55 AM

Document Has Been Signed on 10/03/2024 10:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:EARLY BIRD CARE HOMEFACILITY NUMBER:
335530128
ADMINISTRATOR/
DIRECTOR:		CHANTHARASETH,PATSARAFACILITY TYPE:
740
ADDRESS:11860 CONFLUENCE DRTELEPHONE:
(951) 268-6525
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
91752
CAPACITY: 6CENSUS: 5DATE:
10/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Licensee - William Choi and Patsara ChantharasethTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mary Rico met with Licensee William Choi and Licensee Patsara Chantharaseth to initiate case management visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

During record review, LPA Rico review staff criminal record clearance and staff schedules. LPA Rico observed S1 has been working at the facility since 9/8/2024 without a criminal record clearance. In addition, LPA asked the Licensee if S1 had received their clearance letter. Licensee indicated S1 fingerprint is in process. LPA informed the Licensee that S1 is not allowed to work at the facility until they have an eligible clearance.

During today’s visit the facility a deficiency will be issued and Civil Penalties were assessed with the amount of $500.00 for S1

An exit interview was conducted where this report (LIC809), (LIC809D), (LIC421BG) and Appeal Rights were discussed and provided to Licensee William Choi and Patsara Chantharaseth.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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 10/03/2024 10:59 AM - It Cannot Be Edited


Created By: Mary Rico On 10/03/2024 at 10:23 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EARLY BIRD CARE HOME
FACILITY NUMBER: 335530128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2024
Section Cited
CCR
87355(e)(1)

1
2
3
4
5
6
7
87355 Criminal Record Clearance (e) All individuals 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... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated to not allow S1 to work at the facility without obtaining the required Criminal background clearance and submit copy of Staff Schedule and Personnel Summary Report (LIC500) to LPA Rico at Plan of Correction due date.
8
9
10
11
12
13
14
Based on observation and interview, the Licensee did not comply with the section cited above by not obtaining Staff #1 (S1) criminal record clearance before allowing S1 to work at the facility since 9/8/2024 which pose immediate health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
POC 10/4/2024

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2