<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004561
Report Date: 09/26/2022
Date Signed: 09/26/2022 04:14:28 PM

Document Has Been Signed on 09/26/2022 04:14 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:MAILE ALOHAFACILITY NUMBER:
372004561
ADMINISTRATOR:PEREZ, JOSEPHINE A.FACILITY TYPE:
740
ADDRESS:3636 CHRISTINE STREETTELEPHONE:
(858) 274-0921
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY: 12CENSUS: 8DATE:
09/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Josephine and Orlando PerezTIME COMPLETED:
04:20 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) Rebecca Ruiz conducted an unannounced case management visit to issue a deficiency observed during a complaint investigation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Licensees Josephine and Orlando Perez.

Interviews and records review completed during the complaint investigation revealed that on or around 12/3/2021, the Licensee Josephine Perez told Resident 1 (R1) and their responsible parties that if R1 left the facility to attend an outing, R1 would be required to quarantine in R1’s room for 14 days and would be required to pay $50 a day for in-room meals and a commode placed inside the room. Review of R1’s admission agreement dated 11/1/2019 did not reveal a description or corresponding fee for in-room meals and commode services. The following deficiency was cited per CA Code of Regulations Title 22 and noted on the attached LIC809-D page.

An exit interview was conducted with Licensees Josephine and Orlando Perez, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
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 09/26/2022 04:14 PM - It Cannot Be Edited


Created By: Rebecca A Ruiz On 09/26/2022 at 10:22 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: MAILE ALOHA
FACILITY NUMBER: 372004561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2022
Section Cited

1
2
3
4
5
6
7
87507 Admission Agreements (g) Admission agreements shall specify the following: (3)(B)(1) a comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed.
8
9
10
11
12
13
14
This requirement has not been met as evidenced by: Based on interviews and record review, the admission agreement for R1 did not include a description of a $50 per day fee for services provided during quarantine. This poses a personal rights risk to 12 of 12 residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022


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