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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370803166
Report Date: 09/01/2023
Date Signed: 09/01/2023 03:30:24 PM

Document Has Been Signed on 09/01/2023 03:30 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:MICHAEL GASTELUM A.R.F.FACILITY NUMBER:
370803166
ADMINISTRATOR:GASTELUM, MICHAELFACILITY TYPE:
735
ADDRESS:3705 SINCLAIR LANETELEPHONE:
(619) 465-5208
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 3DATE:
09/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee Michael GastelumTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Michael Gastelum.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 05/05/2023), involving Client #1 (C1) falling at the facility on 04/29/2023. [See LIC 811 Confidential Names List for a description of C1].

During today’s visit, LPA performed a facility tour and welfare check on C1, finding they were safe. LPA interviewed C1 and relevant staff. LPA also reviewed pertinent care and hospital records.

Records, corroborated by interviews, showed: On 04/29/2023, C1 tripped over a piece of carpet tape which had peeled up over time. Licensee had placed the carpet tape in this spot to cover a seam/transition line, where two sections of the facility’s carpet flooring joined together. During the incident, Licensee timely arranged emergency medical care for C1 and met reporting requirements. Following the incident, Licensee replaced the peeling piece of carpet tape with a new piece of tape that laid flatter/smoother to the floor surface (as corroborated by LPA observation).

A preponderance of evidence exits to show that during the above incident, Licensee did not ensure that C1 was protected from a visible trip hazard associated with the facility’s flooring, which contributed to C1’s fall and subsequent injuries. One (1) deficiency was thus cited per California Code of Regulations, Title 22 (see attached LIC 809-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Gastelum, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2023
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 09/01/2023 03:30 PM - It Cannot Be Edited


Created By: Dang Nguyen On 09/01/2023 at 03:18 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: MICHAEL GASTELUM A.R.F.
FACILITY NUMBER: 370803166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2023
Section Cited
CCR
80087(b)

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80087 Buildings and Grounds: “(b) All clients shall be protected against hazards within the facility…” This requirement was not met, as evidenced by:
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During LPA’s site visit, Licensee spoke to their contracted gardener/handyman and made arrangements for that person to install a purpose-made carpet threshold cover/strip over the spot where C1 tripped and fell. Licensee will ensure that this new piece is secure and not subject to movement, once installed. (This cover/strip will allow the carpet tape to be removed). Licensee agreed to send LPA a photograph of the cover/strip in place, by the POC due date.
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Based on records and interviews: During the incident, Licensee did ensure that 1 of 3 clients (C1) was protected against a trip hazard within the facility, which posted an immediate safety 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023


LIC809 (FAS) - (06/04)
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