370808582-8-5-2026-08-AS-CLOZ-DUB2TV-20260521174123

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370808582
Report Date: 05/21/2026
Date Signed: 08/05/2026 12:08:15 PM

Document Has Been Signed on 08/05/2026 12:08 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	RUBIA'S FACILITY CARE HOME		FACILITY NUMBER:	370808582
ADMINISTRATOR/ DIRECTOR:	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:	05/21/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:43 AM
MET WITH:	Mercedes Rubia, Licensee		TIME VISIT/ INSPECTION COMPLETED:	05:50 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) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA identified herself, and was granted entry by caregiver Leonida De Jesus. LPA discussed the purpose of the visit with licensee Mercedes Rubia who was present at the facility alongside caregivers De Jesus and Frances Rubia Key. According to the facility’s license, there may be a maximum of six (6) clients, four (4) of whom may be non-ambulatory in rooms #1 and #2, in at any given time at the facility site. During today’s inspection, the facility’s current census is two (2) clients living at the facility. There were 2 clients present at the facility site during the inspection. The clients attend program but due to their current ailments, they were at the facility ensuring their recovery prior to returning to their respective day program(s). LPA inspected the interior and exterior of the facility and inspected each room. The facility was clean, sanitary and in good repair. Pet excrement were located in a designated caged area on the side of the facility, away from the clients. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, 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 various activities. The facility’s ambient internal temperature was comfortable and compliant, at 74º F. Hot water temperature at taps accessible to clients were also compliant. [CONTINUED ON LIC 809-C]

Robyn Clark
Carmen Lopez
	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: RUBIA'S FACILITY CARE HOME	FACILITY NUMBER: 370808582
	VISIT DATE: 05/21/2026

NARRATIVE

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[CONTINUED FROM LIC 809]

There was at least 2 days of perishable food, and at least 7 days of non-perishable food present. Cooking, dining equipment and utensils were present, and all safely stored. There were no toxic chemicals or poisons accessible to residents. Medications were properly labeled, as required, and stored in locked locker, which LPA inspected. The facility-maintained medication logs, which LPA reviewed. LPA observed that client medications were not given as prescribed for client #1 (C1), as per the Licensee did not want to combine daily medications with discharge medications that C1 took for 7 days. According to the License they did not check with C1s PCP prior to making this decision; or check with the Pharmacy if the discharge medications would counteract with daily medications. Client #2s (C2) medications were provided as prescribed although they also were taking added medications.

No pools or bodies of water on the premises. Per Licensee Rubia, no firearms or ammunition are kept at the facility. The heater in the living room area was inaccessible to the clients. Carbon monoxide detectors were available and on working order. The facility did not have a working facility line or emergency flashlights available. Fire extinguisher was present (01) and serviced within the last 12 months. The first aid kit was complete and readily accessible.

LPA spoke with staff and briefly with clients, but clients were not cognizant or able to communicate with LPA. LPA reviewed staff and resident records. The files that LPA reviewed contained most of the required documents. Confidential records were stored in a locked area. There were administrative documents that required updates. Required licensing postings were observed in a visible area of the facility.

There were deficiencies observed and cited during today's annual inspection and may be found on the LIC809-D pages within this report.

An exit interview was conducted with Licensee Mercedes Rubia, to whom a copy of this report, along with the Licensee/Appeal Rights (LIC9058 03/22), were provided at the conclusion of the visit. The signature below confirms that the documents were received.

LPA requested Licensee Rubia to submit a current Designation of Administrative Responsibility (LIC 308), Personnel Report (LIC 500), and Emergency Disaster Plan (LIC610-E) to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.

NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Carmen Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC809 (FAS) - (06/04)

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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)

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Document Has Been Signed on 08/05/2026 12:08 PM - It Cannot Be Edited

Created By: Carmen Lopez On 05/21/2026 at 03:08 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: 05/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80019(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 (S2) out of 3 staff did not have an LIC508, Criminal Record Statement which posed a potential personal rights risk to persons in care.
	POC Due Date: 06/22/2026
	Plan of Correction
1 2 3 4	Licensee agreed to submit an LIC508 for S2 to LPA via email by POC due date, 06/22/2026.

Type B

Section Cited

CCR

85064(b)

Administrator Qualifications and Duties

(b) All adult residential facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 Administrators did not have an updated administrator's certificate which posed a potential safety and personal rights risk to persons in care.
	POC Due Date: 06/22/2026
	Plan of Correction
1 2 3 4	Licensee agreed to contact the certification unit and request the information that they require for Licensee to be recertified and submit documentation and inform LPA by POC due date, 06/22/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:

	Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/05/2026 12:08 PM - It Cannot Be Edited

Created By: Carmen Lopez On 05/21/2026 at 03:08 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: 05/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 record review, the licensee did not comply with the section cited above in that the facility did not have a quarterly fire drill completed which posed a potential safety risk to persons in care.
	POC Due Date: 11/30/2026
	Plan of Correction
1 2 3 4	The facility agreed to submit a quarterly fire drill commencing May 2026 to include a fire drill for August 2026 and November 2026, to LPA by POC due date, 11/30/2026.

Type B

Section Cited

CCR

80025(b)

All Licensee's, other than governmental entities, who are entrusted to care for and control client's cash resources shall file or have on file, with the licensing agency, a bond issued by a surety company to the State of California, as principal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in that they did not have a current surety bond company which posed a potential personal rights risk to persons in care.
	POC Due Date: 06/22/2026
	Plan of Correction
1 2 3 4	The Licensee agreed to submit an updated surety bond to LPA via email by POC due date, 06/22/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:

	Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/05/2026 12:08 PM - It Cannot Be Edited

Created By: Carmen Lopez On 05/21/2026 at 03:08 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: 05/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.4(e)

Acceptance and Retention Limitations

(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)]. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 (C2) out of 2 clients did not have an updated medical assessment which posed a potential health risk to persons in care.
	POC Due Date: 06/22/2026
	Plan of Correction
1 2 3 4	Facility agreed to make an appointment for C2 to have their medical assessment updated and submit the scheduled appointment or their updated medical assessment to LPA via email by POC due date, 06/22/2026.

Type B

Section Cited

CCR

80070(b)(14)

Client Records

(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and record review, the licensee did not comply with the section cited above in 1 (C1) out of 2 clients did not have their ledger match their funds by the amount of $38.90 and C1 and C2 did not have their personal property and valuables form on file which posed a potential personal rights risk to persons in care.
	POC Due Date: 06/22/2026
	Plan of Correction
1 2 3 4	The facility agreed to go over C1s fuds and ledger and correct the amounts to match and submit updated form to LPA via email; as well as and agreed to submit C1 and C2s personal property and valuables forms to LPA via email by POC due date, 06/22/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:

	Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC809 (FAS) - (06/04)

Page: 8 of 9

Document Has Been Signed on 08/05/2026 12:08 PM - It Cannot Be Edited

Created By: Carmen Lopez On 05/21/2026 at 03:08 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: 05/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)(1)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in multiple knives were in an unlocked kitchen drawer which poses an immediate safety risk to persons in care.
	POC Due Date: 05/22/2026
	Plan of Correction
1 2 3 4	The facility removed the knives from the drawer to a locked cabinet prior to LPAs departure from the facility. This is deemed cleared during today's visit.

Type A

Section Cited

CCR

80075(b)(5)(B)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviewm and record review, the licensee did not comply with the section cited above in 1 out of 2 clients did not receive their medications as prescribed by PCP when they returned from the hospital until their hospital medications were completed - between 3 - 7 days of medication, and without checking with clients PCP - which poses an immediate health risk to persons in care.
	POC Due Date: 05/22/2026
	Plan of Correction
1 2 3 4	Facility agreed to contact the clients PCP to ensure notifications are made and submit an LIC624 to the licensing office with a CC to LPA by POC due date, 05/22/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:

	Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/05/2026 12:08 PM - It Cannot Be Edited

Created By: Carmen Lopez On 05/21/2026 at 03:08 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: 05/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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 record review, the licensee did not comply with the section cited above in 1 (S3) out of 3 staff did not have their health screening which posed a potential health and personal rights risk to persons in care.
	POC Due Date: 06/22/2026
	Plan of Correction
1 2 3 4	Facility agreed to submit a health screening (LIC503) form for S3 to LPA via email by POC due date, 06/22/2026.

Type B

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 record review, the licensee did not comply with the section cited above in 1 out of 3 staff did not have their TB on file which posed a potential health and personal rights risk to persons in care.
	POC Due Date: 06/22/2026
	Plan of Correction
1 2 3 4	Facility agreed to submit a TB result for S3 to LPA via email by POC due date, 06/22/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:

	Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC809 (FAS) - (06/04)

Page: 7 of 9

Document Has Been Signed on 08/05/2026 12:08 PM - It Cannot Be Edited

Created By: Carmen Lopez On 05/21/2026 at 03:08 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: 05/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80073(a)

Telephones

(a) All facilities shall have telephone service on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in that the facility did not have a connected facility phone which poses a potential personal rights risk to persons in care.
	POC Due Date: 06/22/2026
	Plan of Correction
1 2 3 4	Facility agreed to reconnect the facility telephone line and inform LPA once the number is up and operable by POC due date, 06/22/2026.

Type B

Section Cited

CCR

80020(c)

Fire Clearance

(c) A licensee of an Adult Residential Facility or Group Home utilizing secured perimeters shall conduct fire and earthquake drills pursuant to Health and Safety Code section 1531.15(h). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This section was inadvertently included to this POC.
	POC Due Date: 05/21/2026
	Plan of Correction
1 2 3 4	POC is deemed not necessary for this ARF.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:

	Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC809 (FAS) - (06/04)

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