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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530036
Report Date: 11/04/2024
Date Signed: 11/04/2024 05:24:52 PM

Document Has Been Signed on 11/04/2024 05:24 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:CORONADO HOMEFACILITY NUMBER:
335530036
ADMINISTRATOR/
DIRECTOR:		MARBY, RENEEFACILITY TYPE:
735
ADDRESS:205 CORONADO DRIVETELEPHONE:
(310) 940-2828
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 4CENSUS: 1DATE:
11/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:House Manager Dianne JohnsonTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 11/04/2024 at 01:05 PM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA Brown knocked on the door, pressed the doorbell and LPA walked around the home and did not observe any persons inside the home. At 01:10 PM, LPA Brown contacted Administrator Renee Marby and no answer. At 01:15 PM, Administrator Marby called back and said that there's no staff at the home and the client's at the Day Program. LPA Brown explained the purpose of the visit and Administrator Marby indicated that they will contact a staff and will call back LPA Brown. At 01:18 PM, Administrator Marby called back and stated that a staff will be at the facility at 01:45 PM. LPA Brown contacted Administrator Marby and followed up what time staff will arrived, and Administrator Marby answered at 02:45 PM. At 02:47 PM, House Manager Dianne Johnson arrived at the facility and LPA Brown gained access to the home. Administrator Marby was unavailable for the visit. LPA Brown explained the purpose of today's visit to House Manager Johnson .

The facility is a four (4) bedroom, two (2) bathroom home with a kitchen/dining area, living room, and a non-attached garage. The facility is an Adult Residential Facility (ARF) level 4i home vendorized by Inland Regional Center (IRC). The facility is licensed for a capacity of four (4) clients. LPA was accompanied by Facility Manager Johnson to conduct a general overall inspection, review of records, Personal and Incidental (P&I) and medications audit, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed one (1) client during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 69 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs, and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperature tested at 135.5 degrees Fahrenheit. Deficiency will be issued." *** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: CORONADO HOME
FACILITY NUMBER: 335530036
VISIT DATE: 11/04/2024
NARRATIVE
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During the tour of the facility, LPA Brown observed one (1) window screen in disrepair. Technical Violation will be issued. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, labor laws, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPA Brown observed no night lights at the hallway leading to clients' shared bathrooms. Deficiency will be issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, non-attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishable food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA Brown observed no Infection Control Plan developed by the Licensee at the facility. Deficiency will be issued. LPA Brown reviewed one (1) client file for admission agreements, medical assessments/physician reports, Individual Program Plan (IPP), Centrally Stored Medication List. LPA Brown observed Client #1 (C1) Physician Report/Medical Assessment does not indicate the required primary and secondary diagnosis. Deficiency will be issued. LPA Brown also reviewed staff and administrator's file for First Aid/CPR, CPI certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown observed that Staff #2 (S2) does not have the required Tuberculosis test documents in S2 file. Deficiency will be issued.

LPA Brown audited one (1) client medications and no issues were observed. LPA Brown audited one (1) client P&I and no issue observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D LIC9102 TV and Appeal Rights were discussed, and copies were provided to House Manager Dianne Johnson.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 11/04/2024 05:24 PM - It Cannot Be Edited


Created By: Melody Brown On 11/04/2024 at 04:42 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CORONADO HOME
FACILITY NUMBER: 335530036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above y not ensuring that the hot water temperature were maintained to automatically regulate temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Licensee stated to regulate the hot water temperature to not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #2 I(S2) have the required Tuberculosis test documents in S2 file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Licensee stated to submit S2 medical appointment to complete the required TB test with TB test result to LPA Brown on POC due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 11/04/2024 05:24 PM - It Cannot Be Edited


Created By: Melody Brown On 11/04/2024 at 04:42 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CORONADO HOME
FACILITY NUMBER: 335530036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Client #1 (C1) has the required Centrally Stored Prescriptions Medication List maintained in C1 file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Licensee stated to submit proof of contact to C1 Physician to obtain C1 Centrally Stored Medications List to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 11/04/2024 05:24 PM - It Cannot Be Edited


Created By: Melody Brown On 11/04/2024 at 04:42 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CORONADO HOME
FACILITY NUMBER: 335530036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not developing the required Infection Control Plan for the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee stated to submit a copy of Infection Control Plan to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that night lights are mainatined in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee stated to submit proof of night lights maintained in hallways and passages to nonprivate bathrooms to LPA Brown on POC due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 11/04/2024 05:24 PM - It Cannot Be Edited


Created By: Melody Brown On 11/04/2024 at 04:42 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: CORONADO HOME
FACILITY NUMBER: 335530036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(d)(1)
Client Medical Assessments
(d) In addition to Section 80069(c), the medical assessment for clients in ARFs shall include the following: (1) A physical examination of the person, indicating the physician's primary diagnosis and secondary diagnosis, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Client #1 (C1) Physician Report/Medical Assessment has the required primary and secondary diagnosis which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee stated to submit a copy of C1 Physician Report/Medical Assessment with the required primary and secondary diagnosis to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
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