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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602480
Report Date: 12/01/2021
Date Signed: 12/02/2021 10:24:11 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/23/2021 and conducted by Evaluator Natasha Persaud
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20211123100007
FACILITY NAME:SAGE GARDEN AT RANCHO BERNARDO, THEFACILITY NUMBER:
374602480
ADMINISTRATOR:MARIA RINA CHANGFACILITY TYPE:
740
ADDRESS:12295 FRONTERA RDTELEPHONE:
(858) 716-3947
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:6CENSUS: 5DATE:
12/01/2021
UNANNOUNCEDTIME BEGAN:
08:07 PM
MET WITH:Elizabeth Aquino, House ManagerTIME COMPLETED:
10:15 PM
ALLEGATION(S):
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Staff member does not have a criminal record clearance
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Natasha Persaud and Regional Manager, Icela Estrada conducted an unannounced visit to commence a complaint investigation. LPA and RM were greeted and allowed entry into the facility by Staff, Janice Gregorio. LPA and RM identified themselves and discussed the allegation mentioned above with Staff, Janice Gregorio and House Manager Elizabeth Aquino.

During today’s visit, a brief tour of the facility was conducted, reviewed records, and interviewed staff. It was alleged, Staff #1 (S1) is working at the facility without a criminal background clearance. A review of the facility’s personnel summary reflected S1 is not associated to the facility. A further review revealed S1 does not have a criminal record clearance. Facility records documented for S1 are dated back to April 2021. A review of the Department's system reflected S1 requires a criminal record exemption. Licensee did not ensure S1 received a criminal background clearance exemption or an association to the facility. Title 22 Regulations require an individual to obtain a California clearance or a criminal record exemption prior to working or residing in a licensed facility. Continued on an LIC 9099C.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 08-AS-20211123100007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SAGE GARDEN AT RANCHO BERNARDO, THE
FACILITY NUMBER: 374602480
VISIT DATE: 12/01/2021
NARRATIVE
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Based on interviews and documentation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with the House Manager and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents. [See LIC 811 Confidential Names List to identify Staff #1]. A civil penalty in the amount $500 is being assessed on an LIC 412BG.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 08-AS-20211123100007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SAGE GARDEN AT RANCHO BERNARDO, THE
FACILITY NUMBER: 374602480
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2021
Section Cited
CCR
87355(e)(1)
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Criminal Record Clearance. 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: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
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House Manager agreed to remove S1 from the schedule and not allow S1 to return until a criminal background clearance or exemption is obtained. Licensee will consider hiring additional staff to ensure sufficient staffing with an approved criminal record clearance or exemption.
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Based on interviews and documentation, Licensee did not ensure S1 received a criminal record clearance or exemption prior to working at the facility. 1 out of 6 staff do not have a criminal record clearance. This poses an immediate health and safety risk to residents in care.
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The licensee will attend an informal meeting at the regional office to further to discuss. A civil penalty is being assessed.
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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.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3