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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808582
Report Date: 07/18/2023
Date Signed: 07/18/2023 03:24:22 PM

Document Has Been Signed on 07/18/2023 03:24 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 HOMEFACILITY NUMBER:
370808582
ADMINISTRATOR:MERCEDES RUBIAFACILITY TYPE:
735
ADDRESS:12443 OLD POMERADO ROADTELEPHONE:
(858) 397-3030
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 2DATE:
07/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Licensee Mercedes RubiaTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced visit to discuss plan of correction from annual inspection (6/15/2023) with licensee Mercedes Rubia. LPA created new plan of correction with licensee and discussed consequences for not meeting plan of correction by plan of correction due date.

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: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023
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 2
Document Has Been Signed on 07/18/2023 03:24 PM - It Cannot Be Edited


Created By: Alyssa Ramirez On 07/18/2023 at 03:16 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: 07/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2023
Section Cited
CCR
80066(a)(10)

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(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:
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Licensee will ensure that Staff 1 (S1) gets LIC503 and TB test and will email documentation to LPA Ramirez by POC due date.
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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 rights risk to persons in care.
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Type B
08/17/2023
Section Cited
CCR80066(a)(10)

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(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).

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Licensee will ensure that Staff 1 (S1) gets LIC503 and TB test and will email documentation to LPA Ramirez by POC due date.
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This requirement is not met as evidenced by:
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 rights risk to persons 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:Simon Jacob
LICENSING EVALUATOR NAME:Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2