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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808315
Report Date: 06/11/2025
Date Signed: 06/11/2025 04:03:13 PM

Document Has Been Signed on 06/11/2025 04:03 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: 6DATE:
06/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Caregiver Marites ChiapocoTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Marites Chiapoco. LPA also spoke briefly with Administrator Elizabeth Velasco via phone.

According to the facility’s license, the facility has a maximum capacity of six (6) clients, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interview, as of today’s date, there were six (6) clients in care [Client #1 (C1) through Client #6 (C6)], and all were non-ambulatory. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report.] LPA reviewed all available client records. LPA reviewed administrative and training records for all active staff. The clients who were present did not have the verbal skills to be qualified as reliable historians/interviewees. However, LPA found all clients he encountered were safe, calm, alert, and cleanly dressed and cleanly groomed. LPA also interviewed multiple staff who were present.

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 working. Extra linens, hygiene, and Personal Protective Equipment (PPE) supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

[CONTINUED ON LIC 809-C, 1 of 2]
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2025
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 12
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 12
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: 06/11/2025
NARRATIVE
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[CONTINUED FROM LIC 809]

The facility’s ambient internal temperature was complaint at 72 F. Hot water temperature at taps normally accessible to clients were compliant in temperature: Kitchen Sink was 109.4 F, Bathroom #1 Sink was 111.6 F, and Bathroom #2 Sink was 106.9 F. Refrigerators and freezers used to preserve perishable food were complaint in temperature. There were at least (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 and in good condition.

The facility did not have a swimming pool (or similar body of water). The fireplace was screened as required. There were no open-faced heaters, toxic chemicals/poisons, or other hazardous objects accessible to clients. Smoke detectors, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. The facility's fire extinguisher was serviced within the last twelve (12) months. The facility’s license did not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present.

There was a locked area for storage of medication. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Per the Licensee, no firearms or ammunition were kept at the facility. Licensee presented proof of current business liability insurance and surety bond.

During a review of client records, LPA observed, and staff interview confirmed: Licensee did not maintain an updated/current LIC9020 Register of Facility Clients (or equivalent document), as required. C6’s care binder was not present at the facility. (During LPA’s visit, C6 was away at the emergency room and staff had taken C6’s care binder with them, not leaving any duplicate records for C6 at the facility.) For C1 through C5, Licensee did not maintain within their care records the name, address, and telephone number for the clients’ dentist, as required. For C1 through C3, Licensee did not self-complete either a pre-admission appraisal or an LIC9172 Functional Capability Assessment (or equivalent documents), as required. C3 had a Gastronomy Tube and C5 had a Colostomy; both devices are classified under regulation as Restricted Health Conditions. [CONTINUED ON LIC 809-C, 2 of 2]
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC809 (FAS) - (06/04)
Page: 3 of 12
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: 06/11/2025
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2] While a training document showed current active staff had recently been trained by a licensed professional on these devices, Licensee did not maintain a completed and signed Restricted Health Condition Care Plan in C3 and C5’s care binders, as required. For C1 through C3, Licensee did not have proof that the client or their authorized representative had been given the list of Clients’ Personal Rights at time of admission, as required. For C1 through C5, Licensee did not have the client and/or their authorized representative sign the LIC9158 Telecommunications Device Notification Form (or equivalent document) at time of admission, as required.

During a review of training records, LPA observed, and staff interview confirmed: Licensee did not have proof that the facility administrator had completed at least three (3) hours of training on Human Immunodeficiency Virus (HIV) and one (1) hour of training on Tuberculosis (TB) within the last two (2) years, as required. Licensee did not ensure that it’s LIC610D Emergency Disaster Plan included at least one evacuation/shelter location “outside of the immediate” area, as required. Licensee did not maintain proof that 4 of 4 current staff [Staff #1 (S1) through Staff #4 (S4)] were retrained on the LIC610D Emergency Disaster Plan within the last year, as required. Licensee did not have proof that these same staff received training on Personal Protective Equipment (PPE) within the last year, as required.

Seven (7) deficiencies were cited per California Code of Regulations, Title 22, and four (4) deficiencies were cited per California Health and Safety Code (refer to the LIC809-D pages). Since once of these deficiencies is a repeat violation within a twelve (12) month period, a Repeat Civil Penalty of $250 was assessed/charged to Licensee (refer to the LIC421-FC page). Plans of Correction were jointly developed with the Licensee. LPA also issued two (2) Technical Violations (TV) regarding needing to vary the type of disaster covered from quarter-to-quarter during staff disaster drills, and regarding having a First Aid Manual at the facility (refer to the LIC9102-TV pages).

An exit interview was conducted with Caregiver Marites Chiapoco, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV pages, the 421-FC page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today's visit. An electronic set of these same documents was E-mailed to Administrator Elizabeth Velasco.
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 06/11/2025 04:03 PM - It Cannot Be Edited


Created By: Dang Nguyen On 06/11/2025 at 02:19 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: 06/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(b)(2)(C)
Infection Control Requirements
(b) In addition to subsection (a), when one or more clients in the facility are diagnosed with a contagious disease, the following shall apply:  (2) All staff and volunteers providing direct care to a client who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth.  PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection.  (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around clients and annually thereafter. 

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and manager interview, Licensee did not ensure 4 of 4 direct care staff (S1 through S4) received training on PPE within the last year, as required. This posed a potential health risk to 6 of 6 clients (C1 through C4) in care.
POC Due Date: 07/11/2025
Plan of Correction
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2
3
4
Licensee agreed to train S1 through S4 on PPE. The training will include hands-on practice and will cover: a) handwashing, b) how and how often to disinfect commonly touched surfaces, c) how to correctly don and doff surgical masks, N-95 respirators, face shields, gowns, and gloves, d) how perform an N-95 seal check, and e) how to correctly set up a COVID-19 isolation bedroom. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date.
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on records review and staff interview, Licensee did not have proof that the facility administrator (S1) received updated training on HIV and TB within the last two years.This posed a potential health risk to 6 of 6 clients (C1 through C4) in care.
POC Due Date: 07/11/2025
Plan of Correction
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3
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Licensee agreed to arrange for S1 to obtain three (3) hours of refresher training on HIV, and one (1) hour of refresher training on TB, from a qualified education vendor. Licensee agreed to E-mail proof of S1's training completion 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.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2025


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 06/11/2025 04:03 PM - It Cannot Be Edited


Created By: Dang Nguyen On 06/11/2025 at 02:19 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: 06/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 records review and staff interview: For 2 of 6 clients (C3 and C5), who each had a Restricted Health Condition, Licensee did not 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: 07/11/2025
Plan of Correction
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Licensee agreed to write current Restricted Health Condition Care Plans for both C3 and C5, in consultation with each clients’ physician and Licensee’s contracted registered nurse (RN). Licensee agreed to then have the RN train all current staff on these plans, as evidenced in writing. Licensee agreed to E-mail these plans and proof of training completion to LPA, by the POC due date.
Type B
Section Cited
HSC
1565(a)(5)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (5) At least two appropriate shelter locations that can house or supervise, as applicable, individuals served by the facility during an evacuation. One of the locations shall be outside of the immediate area.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and staff interview: Licensee did not ensure tht the facility's written emergency and disaster plan included at least one shelter location outside of the immediate area.
POC Due Date: 07/11/2025
Plan of Correction
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3
4
Licensee agreed to update Box G of its existing LIC610D Emergency and Disaster Plan to include at least one shelter location outside of the immediate area. Licensee agreed to then train current staff (S1 through S4) on the updated plan. Licensee agreed to E-mail a copy of the updated LIC610D and training sign-in sheet 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.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2025


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 06/11/2025 04:03 PM - It Cannot Be Edited


Created By: Dang Nguyen On 06/11/2025 at 02:19 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: 06/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(b)
Other Provisions
(b) If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and staff interview, Licensee did not ensure that 4 of 4 staff (S1 through S4) received annual training on the facility's written emergency disaster plan, to include their individual responsibilities under it. This posed a potential safety risk to 6 of 6 clients (C1 through C6) in care.
POC Due Date: 07/11/2025
Plan of Correction
1
2
3
4
Licensee agreed to update Box G of its existing LIC610D Emergency and Disaster Plan to include at least one shelter location outside of the immediate area. Licensee agreed to then train current staff (S1 through S4) on the updated plan. Licensee agreed to E-mail a copy of the updated LIC610D and training sign-in sheet to LPA, by the POC due date.
Type B
Section Cited
HSC
1565(e)(1)
Other Provisions
(e) A facility shall have all of the following information readily available during an emergency: (1) A roster of individuals served by the facility, with the date of birth for each individual.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and staff interview, Licensee did not have readily available a current/updated roster of individuals served by the facility, with the date of birth for each individual. This posed a potential safety risk to 6 of 6 clients (C1 through C6) in care.
POC Due Date: 07/11/2025
Plan of Correction
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2
3
4
Licensee agreed to update its LIC9020 Register of Facility Clients, and to E-mail a copy of this document 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.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2025


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 06/11/2025 04:03 PM - It Cannot Be Edited


Created By: Dang Nguyen On 06/11/2025 at 03:27 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: 06/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
80070 Client Records: “(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.” This requirement was not met, as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and staff interview, Licensee did not continuously maintain at the facility the complete and current record for 1 of 6 clients (C6). This posed a potential health and personal rights risk to persons in care.
POC Due Date: 06/11/2025
Plan of Correction
1
2
3
4
Licensee agreed to return C6’s binder to the facility as soon as the administrator returns from the emergency room where C6 presently is. This satisfies the Plan of Correction.
Type B
Section Cited
CCR
80070(b)(7)
80070 Client Records: “(b) Each record must contain information including, but not limited to, the following: (7) Name, address and telephone number of physician and dentist, and other medical and mental health providers, if any.” This requirement was not met, as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and staff interview, for 5 of 6 clients (C1 through C5), Licensee did not maintain in their respective care records the name, address, and telephone number of a dentist. This posed a potential health risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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2
3
4
Licensee agreed to coordinate with responsible persons and/or SDRC as needed, to update clients’ face sheets to ensure each client has a dentist’s name, address, and telephone number listed. Licensee agreed to E-mail the updated face sheets for C1 through C6 to LPA, by the POC due date. Going forward, Licensee agreed to collect this information for all new move-ins.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2025


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 06/11/2025 04:03 PM - It Cannot Be Edited


Created By: Dang Nguyen On 06/11/2025 at 03:30 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: 06/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069.2(a)
80069.2 Functional Capabilities Assessment: “(a) In order to determine whether the facility's program meets a client's services needs, the licensee of an ARF shall assess the client's need for personal assistance and care by determining his/her functional capabilities. The assessment shall be in writing, shall be used in developing the Needs and Service Plan…” This requirement was not met, as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and staff interview, for 5 of 6 clients (C1 through C5), Licensee did not have written proof they assessed the clients’ need for personal assistance and care by determining his/her functional capabilities. This posed a potential health risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
1
2
3
4
Licensee agreed to author and have signed an LIC603 Pre-Placement Appraisal, and LIC9172 Functional Capability Assessment, and an LIC625 Appraisal/Needs and Services Plan for C1 through C6, and to E-mail these documents to LPA, by the POC due date. Going forward, Licensee agreed to have these forms completed for all new move-ins.
Type B
Section Cited
CCR
80072(d)
80072 Personal Rights: “(d) At admission, a client and the client's authorized representative shall be personally advised of and given a list of the rights specified in Sections 80072(a)(1) through (10) and in the applicable Personal Rights sections of chapters 2 through 7.” This requirement was not met, as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and staff interview, for 3 of 6 clients (C1 through C3), Licensee did not have proof that they, at time of admission, personally advised and gave the list of Clients’ Personal Rights to the client and their authorized representative. This posed a potential personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
1
2
3
4
Licensee agreed to have form LIC613 Personal Rights – Adult Community Care Facilities signed by the authorized representatives for C1, C2, and C3. Licensee agreed to E-mail the completed LIC613 forms to LPA, by the POC due date. Going forward, Licensee agreed to have these forms completed for all new move-ins.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2025 04:03 PM - It Cannot Be Edited


Created By: Dang Nguyen On 06/11/2025 at 03:33 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: 06/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1524.7
1524.7 Telephone Services and equipment; notice to residents of availability: “The State Department of Social Services shall provide to residential care facilities a form, which the residential care facility shall attach to each resident admission agreement, notifying the resident that he or she is entitled to obtain services and equipment from the telephone company…” This requirement was not met, as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and manager interview, for 5 of 6 clients (C1 through C5), Licensee did not attach to their admission agreement and have signed the required Telecommunications Device Notification form. This posed a potential personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
1
2
3
4
Licensee agreed to have form LIC9158 Telecommunications Device Notification signed by the authorized representatives for C1 though C6, and to E-mail copies of these completed forms to LPA, by the POC due date. Licensee agreed to file these forms in the residents' care files. Going forward, Licensee agreed to have these forms completed for all new move-ins.
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.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2025


LIC809 (FAS) - (06/04)
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