371881347-2-29-2024-18-AS-JSRS-D2WW3B-20240229155542

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 371881347
Report Date: 02/29/2024
Date Signed: 02/29/2024 03:55:50 PM

Document Has Been Signed on 02/29/2024 03:55 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	KELLY'S ALMAGRO VILLA		FACILITY NUMBER:	371881347
ADMINISTRATOR:	WELKER, KELLY		FACILITY TYPE:	740
ADDRESS:	1889 ALMAGRO LANE		TELEPHONE:	(619) 504-5049
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	6	CENSUS: 6	DATE:	02/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Garrett Welker, Licensee		TIME COMPLETED:	04:00 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) Jacqueline Shaw Ross made an unannounced visit to the facility to conduct an annual licensing inspection. LPA was met by Caregiver, Leila Tobias and explained the purpose of the visit. Present at the facility was Administrator Garrett Welker, who left shortly. The facility is a six (6) bedroom, three (3) bathroom one-story home. A tour of the facility was conducted inside and out. LPA conducted a general overall inspection, which included but was not limited to the following: Facility physical plant, food service, medication management, record review and facility administration. During today's inspection, LPA observed the following: Indoor and outdoor passageways were observed to be free from obstruction. There are no pools or bodies of water. Per Miss Tobias, there are no firearms or other dangerous weapons in the facility. Poisons and cleaning agents were observed to be secured and inaccessible to residents in care. Facility fire clearance is maintained in conformity with State Fire Marshal regulations. LPA toured every room in the facility. Rooms designated as resident rooms had the required furnishings and sufficient lighting available. Licensee provided each resident with clean linen, in good repair, and sufficient hygiene products for personal use. The hot water temperature measured at 108 degrees F. The facility had functioning carbon monoxide detectors, multiple smoke detectors, one operable fire extinguisher. The facility was stocked with a two-day supply of perishable food items and a seven-day supply of nonperishable food items. Staff records were reviewed and contained CPR/First Aid training, Health Screening Reports, and annual training. Resident records were reviewed and contained the appropriate medical documents in addition to Resident Appraisal, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication and Destruction Records.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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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Document Has Been Signed on 02/29/2024 03:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KELLY'S ALMAGRO VILLA	FACILITY NUMBER: 371881347
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 [6] out of [6] persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/15/2024
	Plan of Correction
1 2 3 4	Licensee will create and implement a medication dosage log and will submit a copy of the log to the Department by the POC date of 3/15/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KELLY'S ALMAGRO VILLA	FACILITY NUMBER: 371881347
	VISIT DATE: 02/29/2024

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Medications were stored in a locked cabinet and were labeled and maintained in compliance with label instructions. During today's visit the following deficiency was observed:
- The facility did not have a record keeping log of medication given. Deficiency cited.

An exit interview was conducted and copy of this report, along with Licensee/Appeal Rights, was provided at the conclusion of the visit.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC809 (FAS) - (06/04)

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