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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426474
Report Date: 04/13/2022
Date Signed: 04/13/2022 12:33:29 PM

Document Has Been Signed on 04/13/2022 12:33 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:DATO GUEST HOMEFACILITY NUMBER:
336426474
ADMINISTRATOR:DATO, CRISTINAFACILITY TYPE:
740
ADDRESS:22836 PORTER ST.TELEPHONE:
(951) 928-0706
CITY:NUEVOSTATE: CAZIP CODE:
92567
CAPACITY: 6CENSUS: 6DATE:
04/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Cristina Dato, AdministratorTIME COMPLETED:
12:33 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate the investigation into complaint #18-AS-20220405140403. During the investigation, the following violation was observed:

Through staff interviews it was revealed that facility staff did not reach out to any appropriate agency to cross report neglect of Resident One (R1). On or around April 02, 2022, R1 did not receive needed medical services due to being away from the facility for a family visit. Staff One (S1) reported the facility has had previous knowledge of R1's family member not ensuring R1 receives the needed medical services when taking the resident out of the facility in the past. This poses a threat to the health and safety of the resident in care. Therefore, a citation will be issued.

An exit interview was conducted with Dato; this report was reviewed with Dato and a copy provided, along with Appeal Rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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 04/13/2022 12:33 PM - It Cannot Be Edited


Created By: Stephanie Torres On 04/13/2022 at 11:54 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: DATO GUEST HOME
FACILITY NUMBER: 336426474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2022
Section Cited
CCR
87211(a)(1)(D)

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REPORTING REQUIREMENTS: Each licensee shall furnish to the licensing agency such reports as the Department may require, including...: A written report shall be submitted to the licensing agency... within 7 days of the occurrence of any of the events specified in (A) - (D) below....Any incident which threatens the
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The Administrator stated proof of training regarding mandated reporting will be submitted to the Department by POC due date.
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welfare, safety or health of any resident, such as...unexplained absence of any resident. This requirement was not met, as evidenced by: Based on interviews, the Licensee did not ensure any appropriate agency was contacted in order to cross report the neglect of R1.
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Stephanie Torres
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


LIC809 (FAS) - (06/04)
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