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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808582
Report Date: 05/24/2022
Date Signed: 05/24/2022 01:10:35 PM

Document Has Been Signed on 05/24/2022 01:10 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:RUBIA'S FACILITY CARE HOMEFACILITY NUMBER:
370808582
ADMINISTRATOR:MERCEDES RUBIAFACILITY TYPE:
735
ADDRESS:12443 OLD POMERADO ROADTELEPHONE:
(858) 397-3030
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 2DATE:
05/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:48 AM
MET WITH:Mercedes Rubia, LicenseeTIME COMPLETED:
01:31 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Miller conducted a case management visit to cite a deficiency identified during a separate Required 1-Year Annual Visit. LPA was greeted at the front door by Client 1, after identifying herself. C1 told LPA that their caregiver was sleeping and was granted entry to show what room caregiver sleeps in. LPA noticed C1 go into an empty room to make a call and inform that LPA was at the facility. C1 returned to LPA to tell her that the caregiver was not at home and that they were very close by.

Mercedes Rubia, Licensee, arrived 20 minutes after LPA arrived and LPA identified herself and disclosed the purpose of the visit. Licensee stated that a Job Coach named Monica (last name unknown) was told to stay at the facility while Licensee ran an errand for another client. Another staff member, Betty Naguit, is employed by Licensee but had the day off today. Licensee stated that a client will be leaving the facility next Monday because she is planning on closing the facility.

Current clients are ambulatory, do not need assistance with their ADLs, and do not have dementia.

A deficiency was cited Per Title 22, Division 6, Chapter 1 of the California Code of Regulations (see LIC809-D). An immediate civil penalty in the amount of $500 is being assessed today. An exit interview was conducted with Licensee to whom a copy of this report, the LIC421IM, and the Licensee/Appeal Rights (LIC9058) were provided.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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 05/24/2022 01:10 PM - It Cannot Be Edited


Created By: Esther Miller On 05/24/2022 at 12:09 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: RUBIA'S FACILITY CARE HOME
FACILITY NUMBER: 370808582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2022
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
The requirement is not met as evidenced by:
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Licensee arrived within 20 minutes of LPA arrival and will provide an LIC500 to reflect additional coverage. An immediate $500 civil penalty is being assessed for absence of supervision.
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Based on observations and interviews, the licensee did not ensure there was adequate staff for supervision for 2 out of 2 clients. The licensee and staff were absent, which poses an immediate safety risk to clients in care.
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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:Denise Powell
LICENSING EVALUATOR NAME:Esther Miller
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022


LIC809 (FAS) - (06/04)
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