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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808189
Report Date: 05/31/2023
Date Signed: 05/31/2023 12:00:51 PM

Document Has Been Signed on 05/31/2023 12:00 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MARSELL'S A.R.F. #3FACILITY NUMBER:
370808189
ADMINISTRATOR:SELL, MARTHAFACILITY TYPE:
735
ADDRESS:10002 DUNBAR LANETELEPHONE:
(619) 443-6048
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY: 6CENSUS: 5DATE:
05/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administartor Dawnne Melton TIME COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with administrator Dawnne Melton. According to the facility’s license, the facility has a maximum capacity of six (6) clients, of which all must be ambulatory.


LPA, accompanied by administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 116 F, bathroom #1 sink was 116 F and bathroom #2 was 117 F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.



No pools or bodies of water on the premises. Per administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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
Document Has Been Signed on 05/31/2023 12:00 PM - It Cannot Be Edited


Created By: Alyssa Ramirez On 05/31/2023 at 11:43 AM
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: MARSELL'S A.R.F. #3
FACILITY NUMBER: 370808189

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 (C1) out of 5 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2023
Plan of Correction
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Administrator will arrange for C1's to get a TB test and submit results to LPA Ramirez by POC due date.
Type A
Section Cited
CCR
80069(c)(4)
Client Medical Assessments
(c) The medical assessment shall include the following: (4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 (C1 & C2) out of 5 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2023
Plan of Correction
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Administrator will arrange for C1 & C2 to be seen by their physican and have physician complete physician's report. Administrator will email completed phsyician's report to LPA Ramirez by POC due date.
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:Simon Jacob
LICENSING EVALUATOR NAME:Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/31/2023 12:00 PM - It Cannot Be Edited


Created By: Alyssa Ramirez On 05/31/2023 at 11:43 AM
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: MARSELL'S A.R.F. #3
FACILITY NUMBER: 370808189

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80069(d)(1)
Client Medical Assessments
(d) In addition to Section 80069(c), the medical assessment for clients in ARFs shall include the following: (1) A physical examination of the person, indicating the physician's primary diagnosis and secondary diagnosis, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 (C1 & C2) out of 5 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2023
Plan of Correction
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Administrator will arrange for C1 & C2 to be seen by their physican and have physician complete physician's report. Administrator will email completed phsyician's report to LPA Ramirez by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Simon Jacob
LICENSING EVALUATOR NAME:Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MARSELL'S A.R.F. #3
FACILITY NUMBER: 370808189
VISIT DATE: 05/31/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

LPA interviewed staff and reviewed multiple staff and client records/files. LPA interviews did not raise any licensing concerns. Two (2) out of five (5) client files (C1 & C2) were missing physician’s report stating ambulatory status. One (1) out of five (5) (C1) client file was missing TB test results. The rest of the files which LPA reviewed contained required documents. Confidential records were stored in locked area

Deficiencies were cited during today's annual inspection and plan of correction was created with administrator.

An exit interview was conducted with Melton to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4