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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372004561
Report Date: 10/12/2023
Date Signed: 10/12/2023 12:22:47 PM


Document Has Been Signed on 10/12/2023 12:22 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:PEREZ, JOSEPHINE A.FACILITY TYPE:
740
ADDRESS:3636 CHRISTINE STREETTELEPHONE:
(858) 274-0921
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:12CENSUS: 9DATE:
10/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Administrator Josephine PerezTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced case management visit to cite a deficiency revealed during a complaint investigation. The LPA identified himself and explained the purpose of the visit to Administrator Josephine Perez.

A file review along with an interview of the administrator revealed incident reports for multiple falls sustained by Resident #1 (R1) and Resident # 2 (R2) were not submitted to the Department. It was revealed R1 sustained two falls, one on 6/29/23 and a second fall on 7/3/23. Both falls required R1 to be transported to the hospital for further evaluation. R2 had a fall on 8/19/23, and was transported to the hospital for further evaluation.

Based on the evidenced obtained, a deficiency was cited per California Code of Regulations Title 22 and noted on the attached LIC809-D. A plan of Correction was jointly formulated with Administrator Perez..

An exit interview was conducted with Perez, to whom a copy of this report, LIC 9099-D, LIC 811, and Licensee Appeal Rights (LIC9058), were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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 10/12/2023 12:22 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: MAILE ALOHA
FACILITY NUMBER: 372004561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2023
Section Cited
CCR
97211(a)(1)(D)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by:
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Administrator agreed to submit incident reports for the incidents in question, by 10/2023.
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Based on interview and review of records, the licensee did not ensure written reports were not submitted to the licensing agency, which posed a potential health, safety and personal rights risk to 2 of 9 residens in care.
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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 TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
LIC809 (FAS) - (06/04)
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