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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530072
Report Date: 01/24/2025
Date Signed: 01/24/2025 02:00:29 PM

Document Has Been Signed on 01/24/2025 02:00 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VILLA DESCANSO DE AMORFACILITY NUMBER:
365530072
ADMINISTRATOR/
DIRECTOR:		THOMPSON, GABRIELAFACILITY TYPE:
740
ADDRESS:15453 ELM LANETELEPHONE:
(909) 393-6201
CITY:CHINO HILLSSTATE: CAZIP CODE:
91709
CAPACITY: 6CENSUS: 5DATE:
01/24/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Yesenia Castro- CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to this facility to initiate an investigation pertaining to complaint # 56-AS-20250116085916. LPA met with facility caregiver Joaquin Thompson.

During today's visit, LPA conducted interviews with residents, staff, obtained and reviewed facility records, LPA Guerrero observed Staff #1 providing care at the facility without criminal background clearance. Facility caregiver informed LPA that criminal clearance was completed however, clearance record was not on file. LPA observed that Staff #1 was not listed under employee roster, and was not listed under guardian. LPA informed S#1 to leave facility. A deficiency will be issued as this pose potential health, safety and personal rights risks to residents in care.

A civil penalty of $500 for criminal record clearance was assessed for Staff #1 for working at the facility without criminal background clearance.

An exit interview was conducted where this report, LIC809, along with LIC809D, LIC421BG and Appeal Rights were discussed and provided to facility caregiver
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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 01/24/2025 02:00 PM - It Cannot Be Edited


Created By: Paola Guerrero On 01/24/2025 at 10:13 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: VILLA DESCANSO DE AMOR
FACILITY NUMBER: 365530072

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2025
Section Cited
CCR
80019(e)(2)

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80019(e)(2) Criminal Record Clearance
(e) All individuals subject to a criminal record..licensed facility:(1) Submit a valid mailing..the Department. (A) An individual who holds a..mailing address. (2) Obtain a California clearance...Department or. This requirement is not met as evidenced by:
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Administrator will remove (S#1) from the schedule until criminal clearance has been approved. licensee will review the regulation cited and submit a statement of understanding to LPA via email by 01/25/2025.
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Based on observation, interview and record review, the administrator did not comply with the section cited above in requesting a criminal record clearance for (S#1) 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:Efren Malagon
LICENSING EVALUATOR NAME:Paola Guerrero
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
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