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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370803192
Report Date: 01/14/2025
Date Signed: 01/14/2025 12:55:11 PM

Document Has Been Signed on 01/14/2025 12:55 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:ARC OF SAN DIEGO-SOL AND RUTH GERBER FAMILY CENTERFACILITY NUMBER:
370803192
ADMINISTRATOR/
DIRECTOR:		OTERIA "TERI" MEDLEYFACILITY TYPE:
775
ADDRESS:1280 NOLAN AVENUETELEPHONE:
(610) 800-3635
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 186CENSUS: 132DATE:
01/14/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Program Administrator Susana Levack and Case Manager Patricia Ochoa-AvilaTIME VISIT/
INSPECTION COMPLETED:
01:00 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 Program Administrator Susana Levack and Case Manager Patricia Ochoa-Avila.

Today's visit was in response to Licensee’s self-reported death of Client #1 (C1), received at the CCLD San Diego Regional Office on 01/10/2025. [See LIC 811 Confidential Names List for a description of C1]. Per the report, C1 last attended the adult day program (ADP) on 12/23/2024, and on 01/07/2025 ADP staff learned of C1’s death.

During today’s visit, LPA briefly toured the ADP program site, collected and reviewed care records on C1, and interviewed multiple ADP staff. LPA performed a cursory welfare check on the remaining clients in care, finding no immediate safety concerns.

Interviews of ADP staff showed: C1 lived with their family members at a private residence. C1 last attended day program on 12/23/2024, and was in good/normal health that day, with no sign of illness, coughing, or choking. On 01/07/2025, ADP staff phoned C1’s family to inquire when C1 might return to day program from the holiday break. C1’s family members informed ADP staff that C1 had earlier been hospitalized for pneumonia symptoms, that C1 suffered seizure while hospitalized, and that C1 then passed away at the hospital on 01/06/2025.

During a review of records, LPA observed and manager interview confirmed: C1 began attending the ADP on 01/02/2024 (i.e., over a year ago). However, Licensee did not possess a completed LIC602 Physician’s Report (or equivalent Client Medical Assessment document) on C1, as was required.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ARC OF SAN DIEGO-SOL AND RUTH GERBER FAMILY CENTER
FACILITY NUMBER: 370803192
VISIT DATE: 01/14/2025
NARRATIVE
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[CONTINUED FROM LIC 809]

One (1) deficiency was cited per California Code of Regulations, Title 22. A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Program Administrator Susana Levack, to whom a copy of this report, the LIC809-D page, 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: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/14/2025 12:55 PM - It Cannot Be Edited


Created By: Dang Nguyen On 01/14/2025 at 12:43 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: ARC OF SAN DIEGO-SOL AND RUTH GERBER FAMILY CENTER
FACILITY NUMBER: 370803192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2025
Section Cited
CCR
80069(a)(1)

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80069 Client Medical Assessment: “(a)…within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client…which enables the licensee to determine his/her ability to provide necessary health related services to the client...(1) The assessment shall be performed by a licensed physician or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, C1 has passed away and is no longer a client of the ADP, so no further action is required regarding C1’s medical assessment. The Plan of Correction is Satisfied. Licensee agreed to perform a self-audit of records for all remaining clients in care, to ensure all have an LIC602 Physician’s Report or equivalent Client Medical Assessment.
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Based on records review and manager interview, for 1 of 132 clients (C1), Licensee did not obtain a written medical assessment from a licensed physician (or their licensed designee) within 30 calendar days following the acceptance of the client. This posed a potential 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
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