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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804484
Report Date: 07/07/2022
Date Signed: 07/07/2022 02:52:59 PM


Document Has Been Signed on 07/07/2022 02:52 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. JOSEPH'S GUEST HOMEFACILITY NUMBER:
370804484
ADMINISTRATOR:ANGELITA SANCHEZFACILITY TYPE:
740
ADDRESS:1576 CASTEEL COURTTELEPHONE:
(619) 267-5909
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:5CENSUS: 3DATE:
07/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Teofila "Faye" Mayo, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez made an unannounced visit to the facility to initially conduct an annual required licensing inspection with a continuation of a case management visit. LPA identified herself and was granted entry by Administrator Tiofila “Feye” Mayo. LPA met with Administrator Tiofila “Feye” Mayo and discussed the purpose of today’s visit. Licensee Angelita Sanchez later arrived.

During today’s visit, LPA toured the facility while on an annual required inspection and observed the following: exposed electrical wires, missing record, and construction not reported to the licensing agency.

Based on today’s inspection deficiencies were cited and documented on an LIC 809-D. LPA went over California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87211(a)(1)(d) Reporting Requirements; Section 87506(a) Resident Records; Section 3-4200 Facility Evaluation; and Section 87307 (d)(6) Personal Accommodations and Services.

The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with Licensee Sanchez. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided Licensee Sanchez at the conclusion of the visit. The signature below serves as confirmation of receipt of these documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
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 3


Document Has Been Signed on 07/07/2022 02:53 PM - It Cannot Be Edited

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. JOSEPH'S GUEST HOME
FACILITY NUMBER: 370804484

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2022
Section Cited

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3-4200 Facility Evaluation Buildings and Grounds - No fence or approved cover for bodies of water; broken window glass in accessible areas; exposed live electrical wires; .… this requirement was not met as evidenced by:
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Based on observation the facility had exposed electrical wires. This posed a potential health risk to three of three residents in care.
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Type B
07/15/2022
Section Cited

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87506(a) Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.… this requirement was not met as evidenced by:
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Based on records review, the Licensee did not have a resident record for R1 at the facility. This posed a potential health risk to one of three residents 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: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/07/2022 02:53 PM - It Cannot Be Edited

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. JOSEPH'S GUEST HOME
FACILITY NUMBER: 370804484

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/22/2022
Section Cited

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87211(a)(1)(d) Reporting Requirements Any incident which threatens the welfare, safety or health of any resident, … this requirement was not met as evidenced by:
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Based on record review, the Licensee did not report the construction to the licensing agency. This posed a potential safety risk to three of three residents 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: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3