370808625-10-25-2024-08-AS-THOS-DADSMR-20241025140023

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370808625
Report Date: 10/25/2024
Date Signed: 10/25/2024 02:00:45 PM

Document Has Been Signed on 10/25/2024 02:00 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	IGBANTE-ENRIQUEZ RESIDENTIAL CARE II		FACILITY NUMBER:	370808625
ADMINISTRATOR/ DIRECTOR:	GUIA IGBANTE-ENRIQUEZ		FACILITY TYPE:	735
ADDRESS:	953 BROADVIEW STREET		TELEPHONE:	(619) 434-6560
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY: 4		CENSUS: 4	DATE:	10/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:39 AM
MET WITH:	Administrator Jessica Enriquez		TIME VISIT/ INSPECTION COMPLETED:	11:35 AM

NARRATIVE

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Licensing Program Analyst (LPA) Tiffany Holmes 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 Jessica Enriquez.

According to the facility’s license, the facility has a maximum capacity of four (4) clients. During today’s inspection, there were a total of one (1) clients in care, the others were at program.

LPA, accompanied by staff, 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: Bathroom sink was 105.2 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.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

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: IGBANTE-ENRIQUEZ RESIDENTIAL CARE II	FACILITY NUMBER: 370808625
	VISIT DATE: 10/25/2024

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per staff, 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.

LPA conducted interviews and reviewed multiple staff and client records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas.

Deficiencies were observed and cited during today's annual inspection.

An exit interview was conducted with Administrator Jessica Enriquez to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/25/2024 02:00 PM - It Cannot Be Edited

Created By: Tiffany Holmes On 10/25/2024 at 11:13 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: IGBANTE-ENRIQUEZ RESIDENTIAL CARE II	FACILITY NUMBER: 370808625
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068(b)(1)(c)

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069. 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 4 out of 4 clients did not have the written needs and services plans which poses a potential safety risk to persons in care.
	POC Due Date: 11/05/2024
	Plan of Correction
1 2 3 4	Staff will submit all 4 written needs and services plan to CCL by POC due date of 11/05/2024 by email

Type B

Section Cited

CCR

80069(b)

“(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client’s medical assessment. 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 4 clients did not obtain and keep on file documentation of a medical assessment, which posed a potential health and safety risk to persons in care
	POC Due Date: 11/05/2024
	Plan of Correction
1 2 3 4	Licensee stated they will obtain an LIC602 Physician’s Report (or equivalent Medical Assessment) for C1 on 11/4/2024, and will send a copy of it to LPA, by the POC due date of 11/5/2024 by email

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:

Tiffany Holmes

LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024

LIC809 (FAS) - (06/04)

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