Facility Evaluation Report

While at the facility conducting complaint investigation (Complaint # 15-AS-20220826164708), Licensing Program Analyst (LPA) Delmundo learned from Mario Rodriguez, administrator, that the facility staff/LVN (S1) started working January 1, 2021. LPA checked Community Care Licensing (CCL) Guardian Portal and LIS Facility Employee Roster, and observed S1's name not on CCL's system.

LPA discussed the above with the Mario Rodriguez.

Deficiency is cited from Title 22 California Code of Regulations and listed on LIC809D). A $500.00 civil penalty is assessed for deficiency section 1569.17(b)(2)(E). Failure to submit proof of correction by plan of correction due date may result in additional civil penalty.

Deficiency and plan, and proof of correction were discussed.

Exit interview conducted. Appeal Rights, LIC421BG Civil Penalty Assesment. LIC9098 Proof of Correction form, and copy of this report provided.