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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601122
Report Date: 06/30/2022
Date Signed: 06/30/2022 08:57:31 AM

Document Has Been Signed on 06/30/2022 08:57 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ARBOR HOUSEFACILITY NUMBER:
415601122
ADMINISTRATOR:ALEJANDRO, VICTORIAFACILITY TYPE:
740
ADDRESS:330 ARBOR DRIVETELEPHONE:
(510) 825-2287
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 4CENSUS: 3DATE:
06/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:House Manager, Homer BautistaTIME COMPLETED:
09:05 AM
NARRATIVE
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On June 30, 2022, Licensing Program Analysts (LPA) Komal Charitra and Kevin Varilla conducted an unannounced case management visit. LPA Charitra and LPA Varilla met with House Manager, Homer Bautista, and explained the purpose of the visit. LPA also notified Administrator, Victoria Alejandro via telephone the purpose of the visit.

During a plan of correction (POC) visit to the facility on June 30, 2022, LPAs observed 1 staff member and 3 residents. LPAs observed Staff #1 (S1) was not fingerprint cleared to work at the facility. According to the Administrator, S1 has been working at the facility since April of 2022. LPAs reviewed the facility roster and S1 is associated, however does not have fingerprint clearance to be providing care to residents at the facility.

This violation results in an civil penalty of $100 per day x 10 days = $1,000

Report is reviewed with House Manager, Homer Bautista and a copy is provided with appeals rights.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2022
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 06/30/2022 08:57 AM - It Cannot Be Edited


Created By: Komal Charitra On 06/30/2022 at 08:34 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ARBOR HOUSE
FACILITY NUMBER: 415601122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2022
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance: (e) 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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

Violation of this regulation is not met as evidence by:
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Licensee/administrator shall ensure that all employees obtain criminal record clearance and clearance transfer PRIOR to employment or initial presence in the facility. Administrator/Licensee to submit proof of criminal record clearance to CCLD by 7/1/2022.
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Based on records review, and information collected, it was indicated that Staff #1 (S1) is not fingerprint cleared to work at the facility which poses an immediate health and safety threat to residents in care.
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Immediate civil penalty of $1,000 was issued today.

$100 x 10 days = $1,000

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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:Julio Montes
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022


LIC809 (FAS) - (06/04)
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