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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424160
Report Date: 08/12/2021
Date Signed: 06/14/2023 01:27:37 PM

Document Has Been Signed on 06/14/2023 01:27 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HAPPY NEST IIIFACILITY NUMBER:
336424160
ADMINISTRATOR:CAMUA, GEORGEFACILITY TYPE:
740
ADDRESS:3020 E. VISTA CHINOTELEPHONE:
(760) 322-8528
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY: 6CENSUS: 6DATE:
08/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:George Camu, AdministratorTIME COMPLETED:
12:45 PM
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Licensed Program Analyst Yolanda Delgado arrived at the facility to complete the Annual Inspection with an emphasis on Infection Control. During the inspection S1 was found to not have a Criminal Background clearance and no association to the facility. Deficiency has been cited and immediate civil penalties has been assessed for $500.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2021
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 06/14/2023 01:27 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 08/12/2021 at 12:06 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HAPPY NEST III
FACILITY NUMBER: 336424160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/13/2021
Section Cited
CCR
87355(b)

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Criminal Record Clearance: Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement was not met by:
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Licensee agrees to remove (S1) from the schedule until a criminal background clearance request is submitted for (S1) and to be associated to this facility. Licensee shall either submit an updated staff schedule to LPA Delgado or submit proof of request of clearance. Plan of Correction due by 8/13/2021.
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The facility failed to meet this requirement as evidence by (S1) does not have a criminal record clearance on file in our department. The Licensee did not comply with the above regulation with (S1). (S1) has been working in the facility without the Licensee submitting a background clearance and association to the facility. This is an immedaite safety risk to all residents in care.
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(S1) left the facility immediately as observed by LPA.
Licensee agrees to not have (S1) return to the facility unless and until (S1) obtains a criminal record clearance for this facility. This is an immediate safety risk.

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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:Efren Malagon
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2021


LIC809 (FAS) - (06/04)
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