370804823-1-30-2024-08-AS-AROS-CZZ59G-20240130184532

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370804823
Report Date: 01/30/2024
Date Signed: 01/30/2024 06:45:50 PM

Document Has Been Signed on 01/30/2024 06:45 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ST. PAUL'S VILLA		FACILITY NUMBER:	370804823
ADMINISTRATOR:	ELEANOR DOWNING		FACILITY TYPE:	740
ADDRESS:	2340 FOURTH AVENUE		TELEPHONE:	(619) 232-2996
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92101
CAPACITY:	200	CENSUS:	DATE:	01/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	LaTressa Downing, Executive Director		TIME COMPLETED:	12:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers was granted entry into the facility by Administrator LaTressa Downing, after identifying herself and stating the purpose of the inspection. Facility is licensed for 200 residents, of whom 80 may be non-ambulatory on the entire second floor. Facility is approved for locked dementia unit with delayed egress doors on the second floor. Hospice waiver is approved for twelve (12) residents. LPA was accompanied by Administrator Downing, during a tour of the facility, which was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, outside grounds, and food storage areas. There is a fire system in place and the carbon monoxide detectors were operational. The last disaster drill was conducted in January 2024 and conducted quarterly. Exterior and interior passageways were free from obstructions. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. No pools or bodies of water were observed on the premises. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with the required furnishings and appropriate lighting to ensure the comfort and safety of residents. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. There are non-skid mats or strips present in the showers. Resident’s room temperatures were within a comfortable range. Hot water temperature at taps accessible to clients were all compliant. Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. [Continued on 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ST. PAUL'S VILLA	FACILITY NUMBER: 370804823
	VISIT DATE: 01/30/2024

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[Continued on 809]

LPA observed an operational signal system. Medications are locked in carts, not accessible to residents. Carts are kept in the wellness room. Medications were labeled and kept in compliance with label instructions.
LPA interview with staff indicates the facility arranges or assists in arranging medical and dental care appropriate to the conditions and needs of residents. This includes providing assistance with transportation or assisting in arranging transportation for incidental medical and dental appointments.

LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA conducted a review of In-service training procedures. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance.

There are several areas used for activities such as: daily music, exercises, arts/crafts and outings. At the time of visit, LPA observed a small group activity, in which some residents were participating. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet residents’ needs.

Based on today’s inspection, no deficiencies were observed in the areas evaluated. An exit interview was conducted with Executive Director Downing and a copy of this report and Licensee/Appeal Rights - LIC 9058 (rev. 01/16) were provided to Administrator Downing, whose signature on this form acknowledges receipt of these documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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