Facility Evaluation Report

Licensing Program Analyst (LPA) Mita Partoza conducted a case management - deficiencies during a complaint investigation and met with Philipp Perez and Mary Jane Acosta who are the designated administrators in the absence of administartor Juliet Pacaldo.

LPA conducted a facility check while doing the investigation, LPA encountered one of the facility staff (S3) who was directly caring for a resident in room 3.

Based on research the Staff 3 (S3) was not listed on the list of staff that were cleared to directly care for residents at the facility on Guardian. LPA requested to review S3's file and found that the S3 submitted a fingerprint scan and was cleared by DOJ on 04/11/2025 and received a response from CA Department of Social Services (CDSS), Care Provider Management Branch (CPMB) on 4/12/2025.

Based on document review, a letter from (CPMB) was sent to the applicant on 08/06/2025, stating that the S3's application was incomplete and if information is not received by 09/22/2025, the background application will be closed. There was no submission from applicant of the required information by CPMB, and the application was closed. S3 status on the Guardian is separated from the facility since 08/14/2025.

Deficiency is cited for not complying with California Code of Regulations (CCR) Title 22 87355 (e)(3). 87761 Penalties (b)Notwithstanding Section 87761(a)... an immediate penalty of $100 per cited violation per day for a maximum of five (5) days shall be assessed if any individual required to be fingerprinted under Health and Safety Code Section 1569.17(b) has not obtained a California clearance or a criminal record exemption, requested a transfer of a criminal record clearance or requested and be approved for a transfer of an exemption as specified in Section 87355(e) prior to working, residing or volunteering in the facility. An exit interview was conducted with designated administrator Philipp Perez and Mary Jane Acosta. A copy of the report and appeals rights were provided.