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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804788
Report Date: 06/23/2023
Date Signed: 06/23/2023 05:28:42 PM


Document Has Been Signed on 06/23/2023 05:28 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:CASA EL CAJONFACILITY NUMBER:
370804788
ADMINISTRATOR:REBECCA RAYOFACILITY TYPE:
740
ADDRESS:306 SHADY LANETELEPHONE:
(619) 440-1335
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY:99CENSUS: 90DATE:
06/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Administrator Rebecca "Becky" RayoTIME COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Other visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Rebecca “Becky” Rayo.

Today's visit was in response to a 30-day written eviction notice, which Licensee served to Resident #1 (R1) on 04/24/2023. [See LIC 811 Confidential Names List for a description of R1]. Licensee also sent a copy of this eviction notice to the CCLD San Diego Regional Office (RO) (received 04/25/2023).

During today’s visit, LPA performed a brief facility tour, reviewed pertinent care and administrative records, and interviewed relevant staff. As of the date of CCLD’s visit, R1 was no longer a resident of the facility.

Per interviews and records reviewed: R1 had lived at the facility since 2004. During April 2023, there was an occasion where R1 slapped Resident #2 (R2), as witnessed by staff. R2 did not have any injuries. The facility timely notified R1’s psychiatrist, who helped facilitate R1 being taken by law enforcement to a local hospital on a Welfare and Institutions Code 5150 psychiatric hold. After R1 was admitted and while they were still at the hospital, licensee served R1 with a written eviction notice. R1 never came back to the facility. Even prior to the above incident, R1 had episodes of medication refusal, throwing items, and/or speaking aggressively towards other residents in care.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
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 4


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: CASA EL CAJON
FACILITY NUMBER: 370804788
VISIT DATE: 06/23/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

After reviewing the facility’s “House Rules,” which R1 signed upon move in, LPA concluded that licensee had basis to issue a 30-day written eviction notice to R1. However, the written notice which licensee served to R1, in practice, did not fully satisfy regulatory requirements. Three (3) deficiencies were cited per California Code of Regulations were issued, and one (1) Technical Violation (TV) was issued. Plans of Correction were jointly developed with the licensee.

An exit interview was conducted with Rayo, to whom a copy of this report, the LIC809-D pages, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/23/2023 05:28 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: CASA EL CAJON
FACILITY NUMBER: 370804788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/23/2023
Section Cited
CCR
87224(d)

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87224 Eviction Procedures: “(d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.” This requirement was not met, as evidenced by:
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Licensee agreed to amend its general template (which it relies on to draft written eviction letters) to include a field/reminder for staff to describe the specific date(s), place(s), witness(es), and circumstance(s) that are relied upon to justify the eviction. Licensee agreed to then submit a copy of its updated template to LPA by the POC due date.
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Based on record review: For 1 of 90 residents (R1), licensee did not set forth in the notice to quit the reasons relied upon for the eviction with the specifics facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons, which posed a potential personal rights risk to persons in care.
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Type B
07/23/2023
Section Cited
CCR87224(d)(1)(A)

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87224 Eviction Procedures: “(d)(1) The notice to quit shall include the following information: (A) The effective date of the eviction.” This requirement was not met, as evidenced by:
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Licensee agreed to amend its general template (which it relies on to draft written eviction letters) to include a field/reminder for staff to describe the effective date of the eviction (i.e. the date that the notice period expires). Licensee agreed to then submit a copy of its updated template to LPA by the POC due date.
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Based on record review: For 1 of 90 residents (R1), licensee’s notice to quit did not include did not include the effective date of the eviction, which posed a potential personal rights 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 TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/23/2023 05:28 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: CASA EL CAJON
FACILITY NUMBER: 370804788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/23/2023
Section Cited
CCR
87224(d)(1)(C)

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87224 Eviction Procedures: “(d)(1) The notice to quit shall include the following information: (C) A statement informing residents of their right to file a complaint with the licensing agency…including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office.” This requirement was not met, as evidenced by:
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Licensee agreed to amend its general template (which it relies on to draft written eviction letters) to include: 1) a statement informing the resident of their right to file a complaint with the licensing agency, 2) the name, address, and telephone number of the San Diego CCLD Regional Office, and 3) the name, address, and telephone number of the San Diego County Long Term Care Ombudsman office. Licensee agreed to then submit a copy of its updated template to LPA by the POC due date.
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Based on record review: For 1 of 90 residents (R1), licensee’s notice to quit did not include did not include a statement informing the resident of their right to file a complaint with the licensing agency…including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the Long Term Care Ombudsman office, which posed a potential personal rights 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 TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4