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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004561
Report Date: 11/25/2024
Date Signed: 11/25/2024 03:53:16 PM

Document Has Been Signed on 11/25/2024 03:53 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:MAILE ALOHAFACILITY NUMBER:
372004561
ADMINISTRATOR/
DIRECTOR:		PEREZ, JOSEPHINE A.FACILITY TYPE:
740
ADDRESS:3636 CHRISTINE STREETTELEPHONE:
(858) 274-0921
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY: 12CENSUS: 9DATE:
11/25/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Administrator Iren Crieghton TIME VISIT/
INSPECTION COMPLETED:
04:10 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) Sabel Martinez conducted an unannounced Continuation Required Annual Inspection. The LPA was welcomed by Caregiver Marcela Becerra and granted entry to the facility.

The facility was clean, sanitary and in good repair. There were no trip hazards observed through the interior and exterior of the facility. Required licensing postings were observed visibly throughout the facility. Fire extinguishers and carbon monoxide detectors were observed throughout the facility.

The LPA conducted interviews and reviewed staff and resident records. Resident admission agreements, Preplacement appraisals, Absentee notification plan, Emergency Drill logs, and staff training logs were not produced for the LPA's review. Review of records, along with staff interviews revealed two of the nine residents were bedridden. The facility did not have an approved fire clearance for bedridden residents. These deficiencies were cited in an LIC 809D form and a plan of correction was jointly formulated with staff. An immediate $500 civil penalty was assessed for a fire clearance violation.

An exit interview was conducted with Marcela Becerra, to whom a copy of this report, LIC 809D, LIC 811, LIC 421IM, and Licensee/Appeal Right (LIC9058), were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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 4
Document Has Been Signed on 11/25/2024 03:53 PM - It Cannot Be Edited


Created By: Sabel Martinez On 11/25/2024 at 01:59 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: MAILE ALOHA
FACILITY NUMBER: 372004561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)(1)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on review of records, the licensee did not comply with the section cited above in 5 of 5 staff, which posed a potential health, safety or personal rights risk to 9 persons in care.
POC Due Date: 12/20/2024
Plan of Correction
1
2
3
4
Staff agreed to provide training to all staff regarding postural supports, restricted health conditions, hospice care, and care and supervision, and submit training records to the LPA, by 12/20/2024.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on review of records, the licensee did not comply with the section cited above, and did not produce admission agreement and pre-appraisal for several residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
1
2
3
4
 Staff agreed to obtain admission agreements and pre-placement appraisals for R1, R2, R3, R4, R5, R6, and R7. Staff will submit these admission ageements ans appraisals to the LPA, by 12/20/024.
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:Sabel Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/25/2024 03:53 PM - It Cannot Be Edited


Created By: Sabel Martinez On 11/25/2024 at 01:59 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: MAILE ALOHA
FACILITY NUMBER: 372004561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and 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 interview and review of records, the licensee did not ensure emegeency drills were conducted, nor documented, which posed a potential health, safety or personal rights risk to all persons in care.
POC Due Date: 12/20/2024
Plan of Correction
1
2
3
4
Staff agreed to conduct an emergecny drill, document the drill, and submit a log to the LPA, by 12/20/2024.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Sabel Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/25/2024 03:53 PM - It Cannot Be Edited


Created By: Sabel Martinez On 11/25/2024 at 02:33 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: MAILE ALOHA
FACILITY NUMBER: 372004561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on review of records and interviews, the licensee did not comply with the section cited above in 2 of 9 residents, which poses an immediate health, safety or personal rights risk to 2 persons in care.
POC Due Date: 11/26/2024
Plan of Correction
1
2
3
4
Staff agreed to submit an LIC 200 form indicating change of ambulatory status, Fire Inspection Authority form, (LIC9054), and an updated facility sketch to the Department, by 11/26/2024.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Sabel Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4