<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880546
Report Date: 06/20/2023
Date Signed: 06/20/2023 12:22:01 PM


Document Has Been Signed on 06/20/2023 12:22 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,
, CA



FACILITY NAME:ESTANCIA DEL SOLFACILITY NUMBER:
331880546
ADMINISTRATOR:LISA HUNTFACILITY TYPE:
740
ADDRESS:2489 CALIFORNIA AVETELEPHONE:
(951) 268-9697
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY:135CENSUS: 125DATE:
06/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Lisa Hunt, Eexcutive DirectorTIME COMPLETED:
12:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Javina George made an unannounced case management deficiencies visit in correlation to complaint control number 18-AS-20200513115313. The following deficiencies are being cited:
Neglect/lack of care and supervision-staff failed to meet resident's needs:
Resident #1 (R1) was prescribed to use both a nebulizer machine and oxygen concentrator. During dinner R1 was seated at the bar area and observed by Staff #2 (S2) described R1 as “bluish, coughing choking”. S2 helped R1 back to their room, and informed S1 about R1s condition. S1 responded to R1s room to administer oxygen, which was later confirmed to have been the nebulizer. Staff 3 and 4 were making rounds when they observed that R1 was hooked up to the wrong machine. R1 admitted that there was a “mix up with the machine”. R1 also stated the mix up was with the “wires” and “the hose”. S1 stated that the “wires” and “the hose” were tangled and that it was the first time attempting to connect R1 up to the oxygen machine and must have switched it. S1 admitted to picking up the nebulizer machine and setting it on the table. “I remember panicking”. S1 confirmed that she had intended to put R1 on oxygen. S3 and S4 properly connected R1 to the oxygen machine. Hospice was then called to come out to the facility due to R1 having a “change in condition.” It was also determined that S1 failed to notify facility staff and the hospice agency of the mishap. S1 has received verbal and written counseling and the facility provided all staff training on the difference between an oxygen and nebulizer treatment.

In addition the incident described/noted above, the facility failed to follow reporting requirements. The information about the incident of R1 not being hooked up to their oxygen machine as needed, but to their nebulizer was withheld as it was not reported. A deficiency is being cited as the facility did not report the incident as required.

An exit interview was conducted and a copy of this report and appeal rights were provided to Lisa Hunt, Executive Director.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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 2


Document Has Been Signed on 06/20/2023 12:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: ESTANCIA DEL SOL
FACILITY NUMBER: 331880546

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/04/2023
Section Cited
CCR
87468.2(a)(4)

1
2
3
4
5
6
7
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of
1
2
3
4
5
6
7
The licensee failed to ensure that 1 out of 1 times R1 was given the care and supervision based on their needs. This poses a potential health safety and personal rights risk to persons in care.
8
9
10
11
12
13
14
the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on observation and interviews this requirement is not met as evidenced by:
8
9
10
11
12
13
14
The licensee agree to conduct an inservice on personal rights, reminder on training why we train, and notfication of issues and or concerns, encourage to speak up. POC is to be submitted to the department by 5pm on the due date indicated.
Type B
07/04/2023
Section Cited
CCR87211(a)(D)

1
2
3
4
5
6
7
87211Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for
1
2
3
4
5
6
7
hook R1’s oxygen equipment up correctly. This poses a potential health, safety and personal rights risk to persons in care.
8
9
10
11
12
13
14
the resident within seven days of the occurrence... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not net as evidenced by: the licensee failed to report the incident in which staff did not
8
9
10
11
12
13
14
The licensee agree to


POC is to be submitted to the department by 5pm on the due date indicated.
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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2