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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372008448
Report Date: 09/17/2024
Date Signed: 09/17/2024 03:27:41 PM

Document Has Been Signed on 09/17/2024 03:27 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:CASA PACIFICAFACILITY NUMBER:
372008448
ADMINISTRATOR/
DIRECTOR:		LISA DIAZ DUFACILITY TYPE:
772
ADDRESS:321 CASSIDY STREETTELEPHONE:
(760) 721-2171
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY: 14CENSUS: 14DATE:
09/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Program Director Lisa DuTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced visit to discuss a deficiency discovered during a complaint investigation. The LPA identified himself and discussed the purpose of the visit with Program Director Lisa Du.

During the investigation, interviews and review of records, including the facility's absentee notification plan, revealed the facility did not meet reporting requirements. The facility did not submit an Unusual Incident Report for Resident # 1's (R1) AWOL on 07/19/2024, to the Department. This deficiency was cited in an LIC 809D and a Plan of Correction was jointly formulated with Program Director Lisa Du.

An exit interview was conducted with Program Director Lisa Du, to whom a copy of this report, LIC 809D, LIC 811, and Licensee's Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received by Lisa Du.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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 09/17/2024 03:27 PM - It Cannot Be Edited


Created By: Sabel Martinez On 09/17/2024 at 10:36 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: CASA PACIFICA
FACILITY NUMBER: 372008448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2024
Section Cited
CCR
81061(b)(1)(E)

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81061 REPORTING REQUIREMENTS (b) Upon the occurrence, during the operation of the facility, of any of the events specified in Section 81061(b)(1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in Section 81061(b)(2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement was not met as evidenced by:
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Program Director provided the LPA a copy of the submitted incident report. Program Director agreed to review reporting requirement regulations with staff, and Quality improvement tean, and provide the LPA a log of such review, by 10/4/24.
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Based on interviews and review of records, the licensee did not ensure an unusual incident report was submitted to the Department for R1's AWOL, which posed a potential health, safety and personal rights risk to 1 of 14 client 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 Tellez
LICENSING EVALUATOR NAME:Sabel Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


LIC809 (FAS) - (06/04)
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