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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370800558
Report Date: 05/08/2025
Date Signed: 05/08/2025 01:04:44 PM

Document Has Been Signed on 05/08/2025 01:04 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:ST PAUL'S MANORFACILITY NUMBER:
370800558
ADMINISTRATOR/
DIRECTOR:		DAMIEN RAPPFACILITY TYPE:
740
ADDRESS:2635 SECOND AVETELEPHONE:
(619) 239-2097
CITY:SAN DIEGOSTATE: CAZIP CODE:
92103
CAPACITY: 200CENSUS: 106DATE:
05/08/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Executive Director Tim Jeffers and Resident Services Coordinator Carol BraunTIME VISIT/
INSPECTION COMPLETED:
01:30 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) Dang Nguyen conducted an unannounced Case Management Visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Tim Jeffers and Resident Services Coordinator Carol Braun.

The Department’s investigation involved records review and interviews of pertinent facility managers, other sources, and Resident #1 (R1). [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The evidence showed on 04/10/2025, Licensee served a 30-day notice eviction letter upon R1, but did not notify CCLD within five (5) days of service, as required.

The Department subsequently obtained a copy of the eviction letter, finding it deficient in the following ways:
-Licensee did not specify the “effective date of the eviction,” as required.
-Licensee cited in the letter R1’s “continued defiance” of facility rule(s), but did not specify in the letter which specific rule(s) were violated nor provide “specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons,” as required.
-Licensee did not specify in the letter “resources available to assist in identifying alternative housing and care options,” to include “referral services” and “case management organizations,” as required.
-Licensee did not include “a statement informing residents of their right to file a complaint with the licensing agency…including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office,” as required.

[CONTINUED ON LIC 809-C]
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2025
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 7
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: ST PAUL'S MANOR
FACILITY NUMBER: 370800558
VISIT DATE: 05/08/2025
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
26
27
28
29
30
31
32
[CONTINUED FROM LIC 809]

-Licensee did not include the required disclaimer paragraph from California Health and Safety Code Section 1569.683(a)(4), which reads, "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing."

Additionally, during a facility evaluation visit on 09/18/2023, LPA learned that Licensee had about six months earlier installed a new facility administrator / Executive Director, Staff #1 (S1), who was different from the administrator on record with CCLD (the latter person was no longer working at the facility). (Per regulation, Licensees must notify the Department in writing within thirty (30) days of hiring a new administrator.) Instead of citing Licensee for failing to notify CCLD as required, the Department recognized S1 was adjusting to their new role and afforded Licensee an opportunity to self-correct. LPA issued written Technical Assistance (TA) to Licensee providing detailed instructions on the specific paperwork/forms which Licensee needed to submit to the Department by 09/28/2023 to change the administrator on record to S1. However, as of LPA’s 05/06/2025 site visit, Licensee still had not corrected the violation, so a deficiency was issued for it.

Seven (7) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Jeffers and Braun, to whom a copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 05/08/2025 01:04 PM - It Cannot Be Edited


Created By: Dang Nguyen On 05/08/2025 at 11:13 AM
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: ST PAUL'S MANOR
FACILITY NUMBER: 370800558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2025
Section Cited
CCR
87224(f)

1
2
3
4
5
6
7
87224 Eviction Procedures : “(f) A written report of any eviction shall be sent to the licensing agency within five (5) days.” This requirement was not met, as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to immediately rescind the eviction notice letter which was served to R1 on 04/10/2025, and to notify R1 of such in writing. Licensee agreed to E-mail a copy of the rescinding notice to LPA, by the POC due date.
8
9
10
11
12
13
14
Based on records review, Licensee did not send a written report of eviction regarding 1 of 106 residents (R1) to the licensing agency within five (5) days. This posed a potential personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
05/09/2025
Section Cited
CCR87224(d)(1)(A)

1
2
3
4
5
6
7
87224 Eviction Procedures : “(d)(1) The notice to quit shall include the following information: (A) The effective date of the eviction.” This requirement was not met, as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to immediately rescind the eviction notice letter which was served to R1 on 04/10/2025, and to notify R1 of such in writing. Licensee agreed to E-mail a copy of the rescinding notice to LPA, by the POC due date.
8
9
10
11
12
13
14
Based on records review, in the notice to quit regarding 1 of 106 residents (R1), Licensee did not include the effective date of the eviction. This posed a potential personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/08/2025 01:04 PM - It Cannot Be Edited


Created By: Dang Nguyen On 05/08/2025 at 11:22 AM
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: ST PAUL'S MANOR
FACILITY NUMBER: 370800558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2025
Section Cited
CCR
87224(d)

1
2
3
4
5
6
7
87224 Eviction Procedures : “(d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.” This requirement was not met, as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to immediately rescind the eviction notice letter which was served to R1 on 04/10/2025, and to notify R1 of such in writing. Licensee agreed to E-mail a copy of the rescinding notice to LPA, by the POC due date.
8
9
10
11
12
13
14
Based on records review, in the notice to quit regarding 1 of 106 residents (R1), Licensee did not set forth specific facts to include date, place, witnesses, and circumstances concerning the reason(s) for eviction. This posed a potential personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
05/09/2025
Section Cited
CCR87224(d)(1)(B)

1
2
3
4
5
6
7
87224 Eviction Procedures : “(d)(1) The notice to quit shall include the following information: (B) Resources available to assist in identifying alternative housing and care options…” This requirement was not met, as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to immediately rescind the eviction notice letter which was served to R1 on 04/10/2025, and to notify R1 of such in writing. Licensee agreed to E-mail a copy of the rescinding notice to LPA, by the POC due date.
8
9
10
11
12
13
14
Based on records review, in the notice to quit regarding 1 of 106 residents (R1), Licensee did not include resources available to assist in identifying alternative housing and care options, to include referral services and case management organizations. This posed a potential personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 05/08/2025 01:04 PM - It Cannot Be Edited


Created By: Dang Nguyen On 05/08/2025 at 11:25 AM
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: ST PAUL'S MANOR
FACILITY NUMBER: 370800558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2025
Section Cited
CCR
87224(d)(1)(C)

1
2
3
4
5
6
7
87224 Eviction Procedures : “(d)(1) The notice to quit shall include the following information: (C) A statement informing residents of their right to file a complaint with the licensing agency, as specified in Section 87468, subsection (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office.” This requirement was not met, as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to immediately rescind the eviction notice letter which was served to R1 on 04/10/2025, and to notify R1 of such in writing. Licensee agreed to E-mail a copy of the rescinding notice to LPA, by the POC due date.
8
9
10
11
12
13
14
Based on records review, in the notice to quit regarding 1 of 106 residents (R1), Licensee did not include a statement informing residents of their right to file a complaint with the licensing agency, as specified in Section 87468, subsection (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office. This posed a potential personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
05/09/2025
Section Cited
CCR87224(d)(1)(D)

1
2
3
4
5
6
7
87224 Eviction Procedures : “(d)(1) The notice to quit shall include the following information: (D) The following exact statement as specified in Health and Safety Code Section 1569.683(a)(4): ‘In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing.’” This requirement was not met, as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to immediately rescind the eviction notice letter which was served to R1 on 04/10/2025, and to notify R1 of such in writing. Licensee agreed to E-mail a copy of the rescinding notice to LPA, by the POC due date.
8
9
10
11
12
13
14
Based on records review, in the notice to quit regarding 1 of 106 residents (R1), Licensee did not include the following exact statement as specified in Health and Safety Code Section 1569.683(a)(4): “In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing.” This posed a potential personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 05/08/2025 01:04 PM - It Cannot Be Edited


Created By: Dang Nguyen On 05/08/2025 at 11:27 AM
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: ST PAUL'S MANOR
FACILITY NUMBER: 370800558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2025
Section Cited
CCR
87211(g)

1
2
3
4
5
6
7
87211 Reporting Requirements: “(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: (1) Name and residence and mailing addresses of the new administrator. (2) Date he/she assumed his/her position. (3) Description of his/her background and qualifications, including documentation of required education and administrator certification. (A) A photocopy of the documentation is acceptable.” This requirement was not met, as evidenced by:
1
2
3
4
5
6
7
By the POC due date, Licensee agreed to E-mail copies of the following to the CCLD San Diego Regional Office at CCLASCPSanDiegoRO@dss.ca.gov (and CC’ing LPA Dang Nguyen): 1. A signed and dated cover letter from the Licensee: The letter will state that a change in administrator occurred, the effective date of the change, S1’s full name, their contact information, and residence and business mailing addresses; 2. Form LIC308 Designation of Facility Responsibility signed by Licensee; 3. Form LIC508 Criminal Record Statement for S1; 4. From LIC501 Personnel Record and resume for S1; 5. A current RCFE Administrator Certificate for S1; and 6. A copy of S1’s current California’s Driver’s License.
8
9
10
11
12
13
14
Based on LPA observation and manager interviews: Licensee did not notify the Department in writing within thirty (30) days of the hiring of a new administrator. This posed a potential health, safety, and personal rights risk to 1 of 106 residents (R1 though R106) in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2025


LIC809 (FAS) - (06/04)
Page: 7 of 7