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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370800930
Report Date: 05/24/2024
Date Signed: 05/31/2024 11:21:51 PM

Document Has Been Signed on 05/31/2024 11:21 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ST MADELEINE SOPHIES CENTERFACILITY NUMBER:
370800930
ADMINISTRATOR/
DIRECTOR:		DEBRA EMERSONFACILITY TYPE:
775
ADDRESS:2119 E. MADISON AVENUETELEPHONE:
(619) 442-5129
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY: 400CENSUS: 344DATE:
05/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:CEO Debra EmersonTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced follow-up Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with CEO Debra Emerson.

Today's visit was in response to a licensee self-reported client on client incident. LPA initially conducted a case management visit on 03/13/24 regarding this incident and licensee previously submitted an incident report on 03/11/2024. [See LIC 811 Confidential Names List for a description of residents].

Per interviews with staff, outside sources and a records review, on 03/04/24 Client #2 (C2) was seen by a staff member inappropriately touching Client #1 (C1) in a break room. Client #2 cannot advocate for self and C1 was immediately suspended from the program and provided counseling. C2 is longer a client of this Adult Day Program.

CEO Debra Emerson stated that effective immediately, clients are to be supervised at all times. An in-service training will be conducted with all staff to ensure supervision protocols are met at all times.

One (1) deficiency was cited per California Code of Regulations, Title 22, (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the CEO.

An exit interview was conducted with Debra, whose signature below confirms receipt of a copy of this report, the LIC811 and the Licensee Rights (LIC 9058 01/16).

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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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Document Has Been Signed on 05/31/2024 11:21 PM - It Cannot Be Edited


Created By: Liliana Silveira On 05/24/2024 at 02:39 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: ST MADELEINE SOPHIES CENTER
FACILITY NUMBER: 370800930

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2024
Section Cited
CCR
82078(a)

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82078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement. This requirement was not met as evidenced by:
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Licensee has agreed to conduct an in-person training with all care staff to ensure that clients are provided supervision at all times, even when taking breaks. Licensee will submit proof of training by 06/24/24.
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Based on records and interviews, the licensee did not ensure that C1 was provided supervision, causing C2 to inappropriately touch them. This posed a potential serious health 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:Jennifer Lott
LICENSING EVALUATOR NAME:Liliana Silveira
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024


LIC809 (FAS) - (06/04)
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