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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850406
Report Date: 12/17/2024
Date Signed: 12/17/2024 04:32:37 PM

Document Has Been Signed on 12/17/2024 04:32 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SALLY RESIDENTIAL CARE HOME 3FACILITY NUMBER:
565850406
ADMINISTRATOR/
DIRECTOR:		AKINMADE, OLUWATOSINFACILITY TYPE:
740
ADDRESS:953 ANDANTE COURTTELEPHONE:
(818) 274-1809
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY: 6CENSUS: 5DATE:
12/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:10 PM
MET WITH:Flordeliza PaltepTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management - Deficiencies visit to the above facility. The purpose of the visit is to issue citations for deficiencies observed during a complaint visit (CC # 29-AS-20240917164844) under the closed facility Sally’s Residential Care Home, Inc (# 565800706). Upon arrival LPA met with staff, Flordeliza Paltep and explained the reason for the visit. The Administrator stated they were unable to come to the facility but gave permission for staff to sign the report. Entrance interview conducted.

During the course of the investigation, it was revealed that Staff #1 (S1), who is employed by Sunshine Residential Home, LLC, collected all checks for the facility including R1’s August 2024 check (Check # 875, dated 08/01/2024). However, prior to depositing the checks, S1 noticed the check reflected “Sally’s” versus “Sunshine” and assumed it was done in error and corrected the check to reflect “Sunshine” prior to depositing it on 08/13/2024. S1 further stated that S1 was aware that the check belonged to R1 for the services provided to R1 and there was no malicious intent in adjusting the name on the check. Additionally, interviews reflected that the bank reversed the check on 09/13/2024 after the POA contacted the bank regarding the payment however, the facility had not received a replacement check for the services provided. S1 stated that he was interviewed by the detectives regarding the altering of the checks and was cleared of any wrongdoing due to it having no malicious/financial abuse intent. S1 and the licensee was advised that in the future to ensure the check issuer is contacted and a replacement check be requested rather than changing information that is already written.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC809-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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 12/17/2024 04:32 PM - It Cannot Be Edited


Created By: Martha Arroyo On 12/17/2024 at 04:11 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SALLY RESIDENTIAL CARE HOME 3
FACILITY NUMBER: 565850406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2024
Section Cited
CCR
87411(a)

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87411(a) Personnel Requirements – General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement is not met as evidenced by:
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Licensee will review regulation 87411 and submit a statement of understanding to CCL no later than POC due date.
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Based on record review and interviews, Staff #1 (S1) altered the check issued for R1’s monthly services from “Sally’s” to “Sunshine”, which is potential personal rights 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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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