370808582-6-15-2023-08-AS-ARAZ-CSTQAV-20230615120035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370808582
Report Date: 06/15/2023
Date Signed: 06/15/2023 12:00:48 PM

Document Has Been Signed on 06/15/2023 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:	RUBIA'S FACILITY CARE HOME		FACILITY NUMBER:	370808582
ADMINISTRATOR:	MERCEDES RUBIA		FACILITY TYPE:	735
ADDRESS:	12443 OLD POMERADO ROAD		TELEPHONE:	(858) 397-3030
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY: 6		CENSUS: 2	DATE:	06/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator Mercedes Rubia		TIME COMPLETED:	12:15 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 Mercedes Rubia. According to the facility’s license, the facility has a maximum capacity of six (6) clients, of which all must be ambulatory. There was a total of two (2) client in care, per physician’s report all clients are ambulatory. Clients were not seen at the facility due to being at day program.

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 105 F and bathroom #1 sink 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: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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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Document Has Been Signed on 06/15/2023 12:00 PM - It Cannot Be Edited

Created By: Alyssa Ramirez On 06/15/2023 at 11:46 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: RUBIA'S FACILITY CARE HOME	FACILITY NUMBER: 370808582
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in one (1) out of one (1) staff (S1) which poses an immediate health, safety or personal rig.hts risk to persons in care.
	POC Due Date: 06/25/2023
	Plan of Correction
1 2 3 4	Administrator will ensure that Staff 1 (S1) gets LIC503 and TB test and will email documentation to LPA Ramirez by POC due date.

Type A

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in one (1) out of one (1) staff (S1) which poses an immediate health, safety or personal rig.hts risk to persons in care.
	POC Due Date: 06/25/2023
	Plan of Correction
1 2 3 4	Administrator will ensure that Staff 1 (S1) gets LIC503 and TB test and will email documentation 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: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: RUBIA'S FACILITY CARE HOME	FACILITY NUMBER: 370808582
	VISIT DATE: 06/15/2023

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[CONTINUED FROM LIC 809]

LPA interviewed staff and reviewed staff and client records/files. LPA interviews did not raise any licensing concerns. Staff’s (S1) file was missing LIC503 and TB test. All other files which LPA reviewed contained all required documents. Confidential records were stored in locked area.

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

An exit interview was conducted with Rubia 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: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

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