374600276-1-17-2024-08-AS-DSEA-CZKNR4-20240117094051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600276
Report Date: 01/16/2024
Date Signed: 01/17/2024 09:41:15 AM

Document Has Been Signed on 01/17/2024 09:41 AM - 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:	CASA DE CASTRO		FACILITY NUMBER:	374600276
ADMINISTRATOR:	CHERYL M. CASTRO		FACILITY TYPE:	740
ADDRESS:	5581 CHATTANOOGA		TELEPHONE:	(619) 267-3934
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92139
CAPACITY:	6	CENSUS: 6	DATE:	01/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Celeste Castro		TIME COMPLETED:	05:55 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) Dawn Segura conducted an unannounced required annual inspection. LPA identified herself and disclosed the purpose of the visit to facility staff and was granted entry into the facility. Co-administrator, Celeste Castro, arrived a short time later. According to the facility’s license, the facility is licensed for six (6) residents, all of whom may be non-ambulatory. Licensee also has a waiver for one hospice resident. During today’s inspection, there were six (6) residents in care, one of whom receives hospice services. The facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by co-administrator, toured the interior and exterior of the facility. Pathways were free of obstruction and slip hazards. Doors, windows and screens were present and sinks and toilets were in working order. Hygiene supplies and Personal Protective Equipment were present. The facility had sufficient space and equipment to facilitate visitation. The facility’s internal temperature was 75 degrees F. Hot water temperature in bathroom sink in a bathroom that is accessible to residents measured at 112.8 degrees F. During the tour of the facility, LPA observed a knife and scissors stored in an unlocked kitchen drawer. Toxic cleaning supplies and bleach were observed in accessible bathroom cabinets, and AJAX cleaner was observed on a resident bathroom sink. No open-faced heaters, pools, or bodies of water were observed on the premises. Per the administrator, no firearms or ammunition are kept at the facility. Smoke alarms and facility telephone were all in working order. A carbon monoxide detector was observed present in the facility; however, the carbon monoxide detector was not in working order. Prior to the end of the visit, a new carbon monoxide detector was delivered to the facility, installed, and observed to be in working order. Fire extinguisher present in the home was serviced within the last 12 months.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

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 01/17/2024 09:41 AM - 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA DE CASTRO	FACILITY NUMBER: 374600276
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 of 1 carbon monoxide detectors which poses a potential safety risk to 6 of 6 persons in care.
	POC Due Date: 01/22/2024
	Plan of Correction
1 2 3 4	A new carbon monoxide detector, which was observed to be in working order, was purchased and installed in the facility during the visit.

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 rooms observed which posed a potential health and safety risks to 2 of 6 persons in care.
	POC Due Date: 02/06/2024
	Plan of Correction
1 2 3 4	Administrator offered to ensure that staff are provided training in proper storage of disinfectants, cleaning solutions, and items which could pose a danger to residents with dementia. Items were stored in locked cabinets during the visit.

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	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA DE CASTRO	FACILITY NUMBER: 374600276
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 1 of 2 staff, which poses a potential health risk to 6 of 6 persons in care.
	POC Due Date: 02/06/2024
	Plan of Correction
1 2 3 4	Administrator offered to ensure that S1 complete first aid and CPR training. Proof of training will be provided to Community Care Licensing by the POC due date of 2/6/2024.

Type B

Section Cited

CCR

87608(a)(1)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 of 6 residents in care, which posed a potential personal rights risk to persons in care.
	POC Due Date: 01/26/2024
	Plan of Correction
1 2 3 4	Administrator offered to request and obtain physician's orders to be maintained in R1's file for use of a soft tie postural support to improve independent functioning and positioning. Proof of correction will be provided to Community Care Licensing by the POC due dtae of 1/26/2024.

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	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA DE CASTRO	FACILITY NUMBER: 374600276
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 pairs of scissors and 1 knife, which posed a potential safety risk to 2 of 6 persons in care.
	POC Due Date: 02/06/2024
	Plan of Correction
1 2 3 4	Administrator offered to ensure that staff receive training on proper storage of items that could be danger to residents with dementia. Proof of training will be provided to Community Care Licensing by the POC due date of 2/6/2024.

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	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA DE CASTRO	FACILITY NUMBER: 374600276
	VISIT DATE: 01/16/2024

NARRATIVE

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LPA observed the use of a postural support for Resident 1 (R1) [LIC 811 Confidential Names List]; however, there was no physician’s order maintained for the use of the postural support.

LPA interviewed staff and residents. The interviews did not produce any significant licensing concerns. LPA also reviewed staff and resident records/files. Staff who was present and working in the facility at the time of the visit did not have current first aid/CPR training. Medications were stored in a locked cabinet with appropriate labels.

Plans of Correction were jointly developed with the administrator. An exit interview was conducted with Celeste Castro to whom a copy of this report, the LIC 809-D, LIC 811 Confidential Names List, LIC 9102 TAs/TV, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

LIC809 (FAS) - (06/04)

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