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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 134604417
Report Date: 02/05/2024
Date Signed: 02/05/2024 03:33:33 PM

Document Has Been Signed on 02/05/2024 03:33 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:SONRISA VILLA INC.FACILITY NUMBER:
134604417
ADMINISTRATOR:OSCAR CHAVEZFACILITY TYPE:
740
ADDRESS:708 E. 5TH ST.TELEPHONE:
(760) 756-3285
CITY:HOLTVILLESTATE: CAZIP CODE:
92250
CAPACITY: 175CENSUS: 100DATE:
02/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Manager Gabriela ZamoraTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Manager Gabriela Zamora.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 02/01/2024). According to the LIC624: on 01/31/2024, Resident #1 (R1) left the facility on foot. [See LIC 811 Confidential Names List for a description of select person identifiers used.] Facility staff followed R1, but were initially unable to redirect R1 back, leading staff to call 911. R1 returned with staff to the facility about an hour later, unharmed.

During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were indeed safe and unharmed. LPA tested auditory staff alert devices on the facility’s six exterior exit doors. LPA also collected copies of and reviewed pertinent care records and interviewed relevant staff.

According to their latest LIC602 Physician’s Report (dated 02/24/2022), R1 was diagnosed with bipolar disorder. R1 was not diagnosed with Dementia or Mild Cognitive Impairment (MCI). R1’s physician determined that R1 was ambulatory, independent in Activities of Daily Living (ADLs), not confused/disoriented, able to follow instructions, able to communicate needs, and able to leave the facility unassisted. The latest LIC625 Appraisal/Needs and Services Plan (dated 01/13/2022) which Licensee performed on R1 corroborated the above points.


[CONTINUED ON LIC 809-C, 1 of 2]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SONRISA VILLA INC.
FACILITY NUMBER: 134604417
VISIT DATE: 02/05/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

During today’s visit, R1 declined to be interviewed by LPA. However, staff interview showed R1 had a history of refusing medications which were prescribed by their assigned psychiatrist; this was also true during the time of the incident. On 01/31/2023 around 4:00 AM, R1 was hallucinating and claimed to have seen a man inside their bedroom. R1 became troubled and left the facility on foot via the lobby's front doors. Staff #1 (S1) saw R1 as they exited and followed them, trying unsuccessfully to redirect them back to the facility and calling 911. R1 walked around three blocks to the local fire department’s station, where personnel there helped convince R1 to return to the facility. R1 then walked with S1 back to the facility, under the observation of a sheriff’s deputy who arrived later. R1 was unharmed.

During today’s visit, LPA observed (and manager interview confirmed) that the facility’s fire extinguishers had not been serviced within the last twelve (12) months, as was required for Licensee to maintain ongoing compliance with its prior approved Fire Clearance (issued by the local fire authority).

Per manager interview: a) The facility’s lobby front desk is not usually staffed between the hours of 10:00 PM and 6:30 AM; and, b) on the date of LPA’s visit, there were around thirty-one (31) residents in care diagnosed with dementia. During today’s visit, LPA observed: For five of six exterior doors, staff alert devices were present and intact, but staff had them turned off (i.e., deactivated) during the daytime. These doors were not continuously visually monitored by staff. Also, one of two sensors associated with the facility’s lobby entrance doors was not working, effectively allowing the front door to be opened from the inside without triggering a staff alert. Licensee had constructive knowledge of the faulty sensor needing repair since mid-August 2023.

Based on a review of records and confirmed by manager interview, Licensee did not have a current and signed Admissions Agreement for R1, as was required.


[CONTINUED ON LIC 809-C, 2 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SONRISA VILLA INC.
FACILITY NUMBER: 134604417
VISIT DATE: 02/05/2024
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[CONTINUED FROM LIC 809-C, 1 of 2]

Three (3) deficiencies were cited per California Code of Regulations, Title 22 (see the LIC 809-D pages). Since one of the deficiencies was also a violation of the facility’s fire clearance, an immediate civil penalty of $500 was assessed (see the LIC 421-IM page). Plans of Correction was jointly developed with the licensee. LPA also issued Technical Assistance (TA) regarding conducting a reappraisal of R1, and regarding an infection control requirement (see the LIC 9102-TA pages).

An exit interview was conducted with Zamora, to whom a copy of this report, the LIC809-D pages, the LIC9102-TA pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/05/2024 03:33 PM - It Cannot Be Edited


Created By: Dang Nguyen On 02/05/2024 at 03:03 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: SONRISA VILLA INC.
FACILITY NUMBER: 134604417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2024
Section Cited
CCR
87202(a)

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87202 Fire Clearance: “(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.” This requirement was not met, as evidenced by:
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During today’s visit, Licensee contacted a vendor to schedule service for the facility’s fire extinguishers. Licensee agreed to E-mail the completed vendor invoice and a photograph of one of the updated extinguisher service tags to LPA, by 03/05/2024.
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Based on LPA observation and manager interview: Licensee did not maintain ongoing compliance with its prior-approved fire clearance, which posed an immediate safety risk to 100 of 100 residents (R1 through R100) in care.
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Type B
03/05/2024
Section Cited
CCR87705(j)

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87705 Care of Persons with Dementia: “(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.” This requirement was not met, as evidenced by:
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During today’s visit: Licensee activated (turned on) the auditory alarms at each exterior door (other than the lobby front door). Licensee agreed to retrain its staff to: a) keep all such alarms activated 24/7, and b) remind residents that such doors are to be used as emergency exits only. Licensee also contacted a vendor to repair the faulty front door alarm sensor; the appointment is scheduled for 02/08/2024. Licensee agreed to send a copy of the staff training sign-in sheet, a copy of the vendor's completed invoice, and a video of the front door alarm in action (both left and right sides) to LPA, by the POC due date.
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Based on records and interviews, during today’s visit, Licensee did not have continuously active auditory devices or other staff alert features to monitor exits, which posed a potential safety risk to 31 of 100 residents (R2 through R34) 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 02/05/2024 03:33 PM - It Cannot Be Edited


Created By: Dang Nguyen On 02/05/2024 at 03:06 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: SONRISA VILLA INC.
FACILITY NUMBER: 134604417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2024
Section Cited
CCR
87505(a)

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87505 Admissions Agreements: “(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.” This requirement was not met, as evidenced by:
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Licensee agreed to coordinate with appropriate persons, as needed, to complete an Admissions Agreement for R1. Licensee agreed to E-mail a copy of the Admissions Agreement to LPA, by the POC due date. Licensee agreed to conduct an internal audit to ensure that all current residents have a signed Admissions agreement. Licensee agreed to review their internal policies/procedures, to ensure that the signed Admissions Agreement is treated as a required document at time of move-in.
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Based on LPA observation and staff interview, for 1 of 100 residents (R1), licensee did not complete an individual written admission agreement, which posed a potential personal rights risk to persons 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2024


LIC809 (FAS) - (06/04)
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