372004894-1-27-2025-08-AS-AGOH-DDBU6T-20250127141850

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 372004894
Report Date: 01/27/2025
Date Signed: 01/27/2025 02:19:06 PM

Document Has Been Signed on 01/27/2025 02:19 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:	TIERRASANTA VERNANEL CARE HOME		FACILITY NUMBER:	372004894
ADMINISTRATOR/ DIRECTOR:	PANAO, NELLY, D.		FACILITY TYPE:	740
ADDRESS:	11085 ZAGALA COURT		TELEPHONE:	(858) 569-1870
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92124
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 2	DATE:	01/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Administrator Nelly Panao		TIME VISIT/ INSPECTION COMPLETED:	02:20 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) Arian Golbakhsh conducted an unannounced, Required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregiver Mike Polinario. Administrator Nelly Panao joined later in the visit. The facility's license shows a maximum capacity of six (6) non-ambulatory residents. The facility is approved for one (1) hospice resident. During today’s inspection there were two (2) residents in care. LPA and Caregiver Polinario toured the interior and exterior of the facility and inspected each room. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Bathroom sink was 105F and kitchen tap read at 116F. 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. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food. During the tour, LPA noticed evidence of rodent activity in the pantry area. Cooking, dining equipment, and utensils were present. No toxic chemicals, poisons, or knives were accessible to clients. During the tour, LPA noticed two cups of unsecured medications left next to the dining table. Interviews with staff and Administrator Panao revealed the medications are pre-poured for a resident as only the Administrator holds a key for the medication cabinet. Aside from those doses, medications were labeled, as required, and stored in locked areas. [Continued on LIC 809-C...]

Jennifer Lott	TELEPHONE: (619) 767-2311
Arian Golbakhsh	TELEPHONE: 619-675-6017
	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

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 01/27/2025 02:19 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: TIERRASANTA VERNANEL CARE HOME	FACILITY NUMBER: 372004894
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Evidence of rodent activity (rat droppings) were noticed by LPA in the dried goods/pantry area while conducting the facility tour. Based on obserations, the Licensee did not comply with the section cited above in all clients in care (2 of 2) which poses a health and safety risk to persons in care.
	POC Due Date: 02/10/2025
	Plan of Correction
1 2 3 4	Licensee will contact a pest control company to inspect and clear out any rodents in the facility. Licensee will submit proof of inspection/clearance of pests to LPA by POC Due Date.

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.

Jennifer Lott	TELEPHONE: (619) 767-2311
Arian Golbakhsh	TELEPHONE: 619-675-6017
	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/27/2025 02:19 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: TIERRASANTA VERNANEL CARE HOME	FACILITY NUMBER: 372004894
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	2 unsecured cups of medication for a resident were left on a shelf next to the dining table. Based on interviews and observations, Licensee did not comply with the above mentioned regulation, posing a potential health and safety risk for (2 out of 2) clients in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Licensee will hold medication training for staff and submit a training completion sheet to LPA by POC Due Date.

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.

Jennifer Lott	TELEPHONE: (619) 767-2311
Arian Golbakhsh	TELEPHONE: 619-675-6017
	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

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: TIERRASANTA VERNANEL CARE HOME	FACILITY NUMBER: 372004894
	VISIT DATE: 01/27/2025

NARRATIVE

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[Continued from LIC 809...]

No pools or bodies of water exist on the premises. Per caregiver Polinario, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher was serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed two (2) staff and two (2) clients, and interviews did not reveal licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained some of the required documents, and LPA discussed with Administrator Panao of necessary documents. Confidential records were stored in locked areas.

Deficiencies were cited during the inspection for unsecured medications and the presence of pests. An exit interview was conducted with Administrator Panao to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Their signature below confirms receipt of these documents.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Arian Golbakhsh	TELEPHONE: 619-675-6017
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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