<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808315
Report Date: 06/19/2024
Date Signed: 06/19/2024 06:58:47 PM

Document Has Been Signed on 06/19/2024 06:58 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:VELASCO HOME IIFACILITY NUMBER:
370808315
ADMINISTRATOR/
DIRECTOR:		ELIZABETH VELASCOFACILITY TYPE:
735
ADDRESS:1537 LARKHAVEN DRIVETELEPHONE:
(619) 585-1283
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 5DATE:
06/19/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Caregiver Marites Chiapoco and Administrator Elizabeth VelascoTIME VISIT/
INSPECTION COMPLETED:
07:15 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) Dang Nguyen conducted an unannounced visit to continue a Required Annual Inspection which began on 06-14-2024. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Marites Chiapoco. LPA also spoke with Administrator Elizabeth Velasco via phone during the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) clients, of which all may be ambulatory or non-ambulatory, but none may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of five (5) clients in care, of which two (2) were ambulatory, three (3) were non-ambulatory, and none were bedridden. The facility did not feature a secured perimeter or delayed egress doors.

LPA, accompanied by Licensee’s staff, 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 and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was complaint at 73 F. Hot water temperature at taps accessible to clients were also compliant: Kitchen Sink was 111.6 F, Bathroom #1 Sink was 110.7 F, and Bathroom #2 Sink was 109.9 F. Appliances to preserve perishable food were also compliant in temperature: Kitchen Refrigerator was 37 F and Kitchen Freezer was 0 F. Garage Refrigerator was 39 F and Garage Freezer was 0 F. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. [CONTINUED ON LIC 809-C, 1 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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 7
Document Has Been Signed on 06/19/2024 06:58 PM - It Cannot Be Edited


Created By: Dang Nguyen On 06/19/2024 at 04:34 PM
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: VELASCO HOME II
FACILITY NUMBER: 370808315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85075.4(a)
Observation of the Client
(a) The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and interviews: The Licensee did not regularly observe 4 of 5 clients (C1, C3, C4, and C5) for changes in physical functioning, specifically weight gain/loss. This posed a potential health risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
1
2
3
4
For all five clients currently in care (C1 through C5), Licensee agreed to measure the current body weights and record them in those clients’ respective Weight Record forms in their client binders. Licensee agreed to E-mail LPA these logs, by the POC due date. Going forward, Licensee agreed to have its staff weight each client once per month, and to report any unusual changes in weight to the client’s physician, responsible person (if applicable), and San Diego Regional Center (SDRC) Coordinator.
Type B
Section Cited
CCR
80092.1(k)(1)
General Requirements for Restricted Health Conditions
(k) If the licensed health professional delegates routine care, the following requirements must be met for health conditions specified in Sections 80092.3, 80092.4 and 80092.6 through 80092.11: (1) The licensee shall obtain written documentation from the licensed professional outlining the procedures and the names of the facility staff who have been trained in those procedures.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and interviews: For 2 of 5 clients (C1 and C2), who each had a Restricted Health Condition, the Licensee did not maintain written documentation from a licensed professional outlining the procedures of care for those conditions and the names of the facility staff who had been trained on those procedures. This posed a potential health risk to persons to care.
POC Due Date: 07/19/2024
Plan of Correction
1
2
3
4
Licensee agreed to write Restricted Health Condition Care Plans for both C1 and C2, in consultation with each clients’ physician and Licensee’s contracted registered nurse (RN). Licensee then agreed to have the RN train its existing staff on those care plans (to include a skills verification exam for each staff). Licensee agreed to E-mail the training sign-in sheet/documentation to LPA, by the 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 06/19/2024 06:58 PM - It Cannot Be Edited


Created By: Dang Nguyen On 06/19/2024 at 04:34 PM
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: VELASCO HOME II
FACILITY NUMBER: 370808315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80092.1(k)(2)
General Requirements for Restricted Health Conditions
(k) If the licensed health professional delegates routine care, the following requirements must be met for health conditions specified in Sections 80092.3, 80092.4 and 80092.6 through 80092.11: (2) The licensee ensures that the licensed professional reviews staff performance as often as necessary, but at least annually.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interviews, and records review: For 2 of 5 clients (C1 and C2), who each had a Restricted Health Condition, Licensee did not ensure that staff who were tasked with caring for those conditions had their performance on them reviewed at least annually by a licensed professional. This posed a potential health risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
1
2
3
4
Licensee agreed to write Restricted Health Condition Care Plans for both C1 and C2, in consultation with each clients’ physician and Licensee’s contracted registered nurse (RN). Licensee then agreed to have the RN train its existing staff on those care plans (to include a skills verification exam for each staff). Licensee agreed to E-mail the training sign-in sheet/documentation to LPA, by the POC due date. Going forward, Licensee agreed to calendar dates in advance for the RN to perform refresher/repeat training to its direct staff on all client restricted health conditions that are in care.
Type B
Section Cited
CCR
80092.2(a)
Restricted Health Condition Care Plan
(a) If the licensee of an ARF chooses to care for a client with a restricted health condition, as specified in Section 80092, the licensee shall develop and maintain, as part of the Needs and Services Plan, a written Restricted Health Condition Care Plan. The plan must include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interviews, and records review: For 2 of 5 clients (C1 and C2), who each had a Restricted Health Condition, Licensee did develop and maintain a written Restricted Health Condition Care Plan as part of the clients’ Needs and Services Plan. This posed a potential health risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
1
2
3
4
Licensee agreed to write Restricted Health Condition Care Plans for both C1 and C2, in consultation with each clients’ physician and Licensee’s contracted registered nurse (RN). Licensee agreed to E-mail these plans to LPA, by the 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/19/2024 06:58 PM - It Cannot Be Edited


Created By: Dang Nguyen On 06/19/2024 at 04:34 PM
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: VELASCO HOME II
FACILITY NUMBER: 370808315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80092.4(a)(1)
Colostomy/Ileostomy
(a) A licensee of an adult CCF may accept or retain a client who has a colostomy or ileostomy if all of the following conditions are met: (1) The client is mentally and physically capable of providing all routine care for his/her ostomy, and the physician has documented that the ostomy is completely healed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interviews, and record review: For 1 of 5 clients (C1), Licensee retained a client in care who was not mentally and physically capable of providing all routine care to their ostomy themselves. This posed a potential health risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
1
2
3
4
Licensee agreed to write a Restricted Health Condition Care Plan in consultation with its contracted registered nurse (RN) and C1’s physician, then have the RN train its existing direct care staff on said plan (to include a skills verification exam for each staff), documenting such training on an in-service sign in sheet. Licensee agreed to coordinate with C1’s physician, responsible person (if applicable), and San Diego Regional Center (SDRC), securing from each signed and dated letters of endorsement for C1 continuing to live at Velasco Home II with ongoing staff assistance to C1 for their colostomy care. By the POC due date, Licensee agreed to Email to CCLASCPSanDiegoRO@dss.ca.gov (and to Cc: LPA) a packet containing the following: 1. An Exception Request Cover Letter requesting approval for Licensee to continue retaining C1 in care despite 80092.4(a)(1), 2. A recently updated LIC602 Physician’s Report for C1, 3. A recently updated LIC625 Appraisal/Needs and Services Plan (or equivalent reappraisal document) for C1, 4. A detailed Restricted Health Condition Care Plan for C1’s colostomy, 5. The aforementioned training sign-in sheet, and 6. The aforementioned letters of endorsement.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and interviews: Licensee did not conduct an emergency/disaster drill at least quarterly for each shift, which posed a potential safety risk to 5 of 5 clients (C1 through C5) in care.
POC Due Date: 07/19/2024
Plan of Correction
1
2
3
4
Licensee agreed to perform and document in writing an emergency/disaster drill on its overnight (NOC) shift, and to E-mail such documentation to LPA, by the POC due date. Going forward, Licensee agreed to ensure that AM, PM, and NOC shifts are each drilled at least once per quarter, and to record such drills in writing.
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 Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
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: VELASCO HOME II
FACILITY NUMBER: 370808315
VISIT DATE: 06/19/2024
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
26
27
28
29
30
31
32
[CONTINUED FROM LIC 809]

There were no sharp objects, toxic chemicals/poisons, active fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. No pools or bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguisher was serviced within the last twelve (12) months. A complete first aid kit was present and readily accessible. Required licensing postings were observed in visible areas of the facility. Licensee also presented proof of current/active business liability insurance and surety bond.

LPA also reviewed all clients' records and multiple staff records. During this process, LPA observed, and manager and staff interviews confirmed: a) Client #1 (C1) had a colostomy and Client #2 (C2) had a urostomy, and both clients were under the medical care of a licensed professional. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report.] C2 was able to provide routine care for their own urostomy. However, C1 was not mentally and physically capable of personally performing routine care for their own colostomy, which was a requirement for C1 to be retained at the facility. Licensee also had not applied for an Exception Request from CCLD to retain C1 in spite of this.; b) According to regulation, C1’s colostomy and C2’s urostomy were both classified as “Restricted Health Conditions.” However, Licensee had not developed and maintained written and complete Restricted Health Condition Care Plans for either C1 or C2, as was required.; c) Interviews widely showed C1 and C2’s assigned facility caregivers possessed requisite knowledge/skill to care for C1 and C2’s Restricted Health Conditions, and that staff had received past initial training on these conditions. However, Licensee did not maintain written documentation outlining the procedures of said care and the names of the facility staff who had been initially trained on them, as was required.; d) Licensee also did ensure that a licensed professional reviewed the caregivers’ performance (on caring for these devices) at least annually, as was required.

LPA saw C1 actively use a wheelchair seatbelt during a site visit. Manager and staff interviews revealed that C2 and Client #3 (C3) also intermittently use wheelchair seatbelts. However, for each of these clients, Licensee did not maintain on file written orders from a physician indicating their client’s need for their respective postural support, as was required. [CONTINUED ON LIC 809-C, 2 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: VELASCO HOME II
FACILITY NUMBER: 370808315
VISIT DATE: 06/19/2024
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
26
27
28
29
30
31
32
[CONTINUED FROM LIC 809-C, 1 of 2]

Also, for four (4) of the five clients in care [C1, C3, Client #4 (C4), and Client #5 (C5)], it had been over ten (10) months since Licensee last obtained the clients’ body weight measurement. (Regulation required Licensee to regularly observe clients, to include changes in weight.)

Records review and interviews further showed that while Licensee performed quarterly emergency/disaster drills over the last year, such drills did not include the overnight (NOC) shift, as was required.

Seven (7) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued Technical Assistance (TA) regarding staff auditory alert devices on exit doors (refer to the attached LIC 9102-TA page).

An exit interview was conducted with Velasco, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TA page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 06/19/2024 06:58 PM - It Cannot Be Edited


Created By: Dang Nguyen On 06/19/2024 at 06:05 PM
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: VELASCO HOME II
FACILITY NUMBER: 370808315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(8)(B)
Personal Rights
(B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and interviews: For 3 of 5 clients (C1, C2, and C3), who each used a Postural Support, Licensee did not obtain, and maintain in the client’s record of care, a written order from the client’s physician indicating the need for the postural support. This posed a potential personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
1
2
3
4
For C1, C2 and C3 each, Licensee agree to contact the respective physician to obtain a written order saying the wheelchair seatbelt is needed by the client. Licensee agreed to E-mail these orders for C1, C2, and C3 to LPA, by the POC due date. Should any physician decline to write an order for their client’s wheelchair seatbelt, then Licensee agrees to immediately cease using it for that specific client, and to E-mail LPA notifying him of such.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
Page: 7 of 7