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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370801951
Report Date: 11/22/2023
Date Signed: 11/22/2023 05:16:21 PM

Document Has Been Signed on 11/22/2023 05:16 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:CAVELARIS COMMUNITY CARE CENTERFACILITY NUMBER:
370801951
ADMINISTRATOR:ARLENE DOULOPOULOSFACILITY TYPE:
735
ADDRESS:9975 SAN JUAN STREETTELEPHONE:
(619) 466-6759
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 22CENSUS: 22DATE:
11/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH: Ron Locke, House MangerTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Rodgers a conducted a unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by house manager, Ronald Locke, to whom LPA dscussed the purpose of the visit. According to the facility’s license, the facility has a maximum capacity of twenty two (22) Mentally Disabled Adults, ages 18-59. All of whom are ambulatory.


LPA, accompanied by Care Giver Phuc Huynh, toured the interior and exterior of the facility, and inspected each room. The facility was adequately clean in most areas and in adequate repair. Pathways were free of obstruction and slip hazards however surrounding yard had many piles of junk that need to be removed. Client bedrooms contained the required furnishings. Doors, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients.



No pools or bodies of water on the premises. Per House Manger Locke, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible.


[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2023
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 7
Document Has Been Signed on 11/22/2023 05:16 PM - It Cannot Be Edited


Created By: Amy Rodgers On 11/22/2023 at 02:18 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: CAVELARIS COMMUNITY CARE CENTER
FACILITY NUMBER: 370801951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, which effected two (R1 and R2) of 22 residents, which possed immediate risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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LPA observed House Manger nail board across window and took glass out of window.
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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4
Based on observation and measurment, the licensee did not comply with the section cited above in 3 of 4 faucets which poses an immediate health rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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While LPA present House Manger turned down water heater. House manager will continue to monitor. LPA measured water temp before leaving facility and water temp was compliant.
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:Denise Powell
LICENSING EVALUATOR NAME:Amy Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 11/22/2023 05:16 PM - It Cannot Be Edited


Created By: Amy Rodgers On 11/22/2023 at 02:18 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: CAVELARIS COMMUNITY CARE CENTER
FACILITY NUMBER: 370801951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 of 1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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LPA requested cabinet to be locked and observed Care giver locking cabinet. Medication traiing is needed.
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:Denise Powell
LICENSING EVALUATOR NAME:Amy Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/22/2023 05:16 PM - It Cannot Be Edited


Created By: Amy Rodgers On 11/22/2023 at 02:18 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: CAVELARIS COMMUNITY CARE CENTER
FACILITY NUMBER: 370801951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)(2)(B)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:  (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (B) Walls and window coverings in client care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 of 2 common inside area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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will clean dirt in corners, on the fridges, common drinking waters spouts by POC date
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 5 of 25 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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Will repair or replace screens by POC dates
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:Denise Powell
LICENSING EVALUATOR NAME:Amy Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 11/22/2023 05:16 PM - It Cannot Be Edited


Created By: Amy Rodgers On 11/22/2023 at 02:18 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: CAVELARIS COMMUNITY CARE CENTER
FACILITY NUMBER: 370801951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review and interview, the licensee did not comply with the section cited above in1 of 1 poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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House Manger agreed to conduct Disaster Drill and provided documentation by POC date
Type B
Section Cited
CCR
80066(a)(10)
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: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 of 5 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
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:Denise Powell
LICENSING EVALUATOR NAME:Amy Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 11/22/2023 05:16 PM - It Cannot Be Edited


Created By: Amy Rodgers On 11/22/2023 at 02:18 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: CAVELARIS COMMUNITY CARE CENTER
FACILITY NUMBER: 370801951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 record review, the licensee did not comply with the section cited above in 4 of 5 records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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3
4
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on record review, the licensee did not comply with the section cited above in 5 of 5 records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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House manager agrees to have staff update and provide tests by POC
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:Denise Powell
LICENSING EVALUATOR NAME:Amy Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023


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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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CAVELARIS COMMUNITY CARE CENTER
FACILITY NUMBER: 370801951
VISIT DATE: 11/22/2023
NARRATIVE
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[CONTINUED FROM LIC 809]


LPA interviewed clients and reviewed multiple staff and client records/files. LPA interviews did not raise any licensing concerns. The client files which LPA reviewed contained required documents.

Staff records review verified that all staff records were not complete and compliant. All the direct care staff did not have First Aid certificates. LPA observed the e front common area was in disarray and the common water/juice containers were unsanitary. Medications were labeled, as required however a cabinet where medication was stored with multiple pills of multiple prescriptions was unlocked and accessible to clients.

Some of the required licensing postings were observed in visible areas of the facility. Confidential records were not stored in locked areas.

In one bedroom a window was broken and jagged edges were protruding. This effected R1 and R2 (see confidential names list). Staff indicated window had been broken for several weeks but they left it in disrepair until client R1 moved out.

LPA Rodgers did leave for lunch and returned to finish annual visit.

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 House Manger Ronald Locke.

An exit interview was conducted with House Manger Ronald Locke, to whom copies of this report, the LIC 809-D pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
LIC809 (FAS) - (06/04)
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