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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804788
Report Date: 11/13/2023
Date Signed: 11/13/2023 04:45:34 PM


Document Has Been Signed on 11/13/2023 04:45 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: 98DATE:
11/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Administrator Rebecca "Becky" RayoTIME COMPLETED:
05:00 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 Administrator Rebecca “Becky” Rayo.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 11/07/2023). According to the LIC624, during the late evening of 11/06/2023, Resident #1 (R1) left the facility without informing staff or signing themselves out on the facility's logbook. [See LIC 811 Confidential Names List for a description of C1.]

During today’s visit, LPA performed a brief facility tour and interviewed R1 (who had since returned to the facility), finding they were unharmed. LPA also collected copies of pertinent care records, and interviewed relevant staff and R1's roommate.

According to R1’s latest LIC602 Physician’s Report (dated 06/27/2023): R1 was diagnosed with “Schizophrenia, bi-polar type,” but did not have Dementia or cognitive impairment. Their doctor determined that R1 was able to follow instructions, able to communicate needs, and “able to leave the facility on [their] own and return on [their] own.” R1 was also independent in all Activities of Daily Living (ADLs), except for medication assistance.

R1’s independence with personal care was also evidenced in other facility and third-party care records. R1's Facesheet also showed that they were their own Responsible Person (RP).

[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: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023
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 3


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: 11/13/2023
NARRATIVE
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[CONTINUED FROM LIC 809-C]

Interview of R1, their roommate, and staff, corroborated by dated and written progress notes, showed: During the 11/06/2023 incident, R1 left the facility without telling staff or signing themselves out on the logbook, as was required in the House Rules with R1 signed upon admission. Facility staff provided needed observation and timely recognized that R1 was not present during a routine room check. Staff followed the facility’s Absentee Notification Plan and timely notified law enforcement and R1’s psychiatrist. Around 24 hours later, R1 had returned to the facility on their own, unharmed.

During review of the facility’s care records on R1: LPA observed that while R1 had a completed LIC9172 Functional Capabilities Assessment, the LIC603 Pre-Placement Appraisal which Licensee performed on R1 was incomplete (several missing fields). LPA also observed that R1’s LIC625 Appraisal/Needs and Services Plan was blank and not signed.

Interview of the administrator confirmed that R1 was referred to the facility by their assigned psychiatrist, but the Licensee or their staff did not personally meet with R1 prior to move in, for the purpose of completing an independent, pre-admission appraisal interview.

One (1) deficiency was thus cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Rayo, 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/13/2023 04:45 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: 11/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2023
Section Cited
CCR
87465(a)(1)

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87456 Evaluation of Suitability for Admission: “(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall…(1) Conduct an interview with the applicant…” This requirement was not met, as evidenced by:
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Licensee agreed to finish writing R1’s LIC603 Pre-Placement Appraisal and LIC625 Appraisal/Needs and Services Plan, and to E-mail signed copies of both to LPA, by the POC due date.
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Based on records and interviews, for 1 of 98 residents (R1), Licensee did not interview the applicant to evaluate their suitability, prior to accepting them for care. This posed a potential health, safety, and 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: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023
LIC809 (FAS) - (06/04)
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