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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426750
Report Date: 01/17/2024
Date Signed: 01/17/2024 11:34:12 AM

Document Has Been Signed on 01/17/2024 11:34 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PARTNERS N CARE-CARE HOMEFACILITY NUMBER:
336426750
ADMINISTRATOR:VAUGHAN, BEVERLEEFACILITY TYPE:
740
ADDRESS:5920 COPPERFIELD AVETELEPHONE:
(951) 213-6591
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 5DATE:
01/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Karin Vaughn, Facility ManagerTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct a Case Management visit in regards to RO receiving a telephone call for a self-reporting of financial abuse by a staff. LPA met with Karin Vaughn, Facility Manager and explained the the nature of the visit. LPA conducted an interview, requested and obtained copies of pertinent documentation, five residents in care with two (2) staff on duty. LPA did not observe any health and safety concerns during the visit. No immediate health and safety codes, sufficient food and working utilities.


The facility will be cited for violation of California Code of Regulations, Title 22, Division 6, Chapter 3, Section 1550(c). This poses a health and safety risk to residents in care.

An exit interview was conducted, a copy of this report, along with the 809-D and appeal rights were provided to Facility Manager Karin Vaughn
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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 01/17/2024 11:34 AM - It Cannot Be Edited


Created By: Yolanda Delgado On 01/17/2024 at 10:33 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: PARTNERS N CARE-CARE HOME
FACILITY NUMBER: 336426750

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
01/18/2024
Section Cited
HSC
1550(c)

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Licenses or administrator Certificates; suspension, revocation or denial of application; grounds: The department may...revoke, any license, or any special permit, certificate of approval, or administrator certificate, issued under this chapter upon any of the following : (2) Conduct which is inimical to the health, morals, welfare or safety
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Licensee shall ensure that all staff is conducting themselves in a professional manner. Licensee will read the health and safety code and submit a statement of understanding regarding inimical conduct.
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of either the people of this state or an individual in, or receiving services from the faciltiy or certified family home. This
requirement is not met as evidenced by: Interviews and record reviews revealed S1 took a check from R1's son for payment to the facility and cashed it in personal account and left the country. This poses an immediate health and 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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
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