<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603083
Report Date: 12/28/2022
Date Signed: 12/28/2022 01:33:45 PM

Document Has Been Signed on 12/28/2022 01:33 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ANGELS IN GRACEFACILITY NUMBER:
374603083
ADMINISTRATOR:CASTRO, MARIA EUGENIAFACILITY TYPE:
740
ADDRESS:349 VIA METATETELEPHONE:
(760) 724-2354
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 5DATE:
12/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rosio Maribel FerrerTIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Rebecca Ruiz conducted a complaint investigation visit where an unrelated deficiency was discovered. LPA was greeted by, identified herself to, and explained the purpose of the visit to Caregiver Rosio Maribel Ferrer. LPA spoke to Administrator Maria Eugenia Castro via telephone.

During the visit, LPA observed Staff 1 (S1) present at the facility. A review of the Department clearance system revealed that S1 does not have a criminal background clearance from the Department. Per California Code of Regulations Title 22, the following deficiency is cited on the attached LIC809-D page. A civil penalty in the amount of $100 has been assessed during the visit.

An exit interview was conducted with Caregiver Rosio Maribel Ferrer with Administrator Maria Eugenia Castro on the telephone, and a copy of this report, the LIC421BG (6/17), and the Licensee Appeal Rights (LIC9058 01/16) were provided to Rosio Maribel Ferrer via hard copy.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2022
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 12/28/2022 01:33 PM - It Cannot Be Edited


Created By: Rebecca A Ruiz On 12/28/2022 at 12:00 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANGELS IN GRACE
FACILITY NUMBER: 374603083

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/29/2022
Section Cited
CCR
87355(e)(1)

1
2
3
4
5
6
7
87355 Criminal Record Clearance (e) all individuals subject to a criminal record review persuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility (1) obtain a California clearance or a criminal record exemption as required by the Department.
1
2
3
4
5
6
7
LPA verified that S1 left the facility prior concluding the visit. Administrator will submit a letter to the Department stating that S1 will not return to the facility until receiving a cleared background check by POC due date.
8
9
10
11
12
13
14
This requirement has not been met as evidenced by: Based on observation, interviews and record review, S1 did not obtain a criminal background clearance prior to working at the facility. This poses an immediate health and safety risk to 5 of 5 residents in care. A civil penalty of $100 was assessed.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2