374600488-2-13-2025-08-AS-DNGN-DDV3DX-20250213171016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600488
Report Date: 02/13/2025
Date Signed: 02/13/2025 05:10:49 PM

Document Has Been Signed on 02/13/2025 05:10 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	CASA DE LAS CAMPANAS		FACILITY NUMBER:	374600488
ADMINISTRATOR/ DIRECTOR:	KIMBERLY FINCH-DOMINY		FACILITY TYPE:	741
ADDRESS:	18655 WEST BERNARDO DRIVE		TELEPHONE:	(858) 451-9152
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92127
CAPACITY: 582		CENSUS: 482	DATE:	02/13/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Director of Residential Health Shila Jurado		TIME VISIT/ INSPECTION COMPLETED:	05:15 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) Dang Nguyen conducted an unannounced visit to continue a Required Annual Inspection which began on 01/21/2025. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Director of Residential Health Shila Jurado. According to the facility’s license, the facility has a maximum capacity for five-hundred eighty-two (582) residents, of which two-hundred twenty-seven (227) may be non-ambulatory but none may be bedridden, and of which twenty (20) may be under hospice care. Per LPA observation, review of sampled LIC602 Physician’s Reports, facility records, and staff interviews: During this annual inspection, there were a total of four-hundred eighty-two (482) residents in care, of whom one-hundred nineteen (119) were non-ambulatory, and none were bedridden. Six (6) of the residents were under hospice care. The facility’s license included endorsement for use of delayed-egress doors in the facility’s dementia-care unit. During this inspection, LPA observed and tested the function of the two (2) delayed-egress doors, finding they were operational and consistent with regulatory requirements. LPA reviewed records for multiple residents and multiple staff. LPA interviewed multiple residents and multiple staff. LPA, accompanied by Licensee’s staff, also toured the interior and exterior of the facility, and inspected common areas and multiple resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Multiple resident pendant, push-button, and pull-cord call devices were tested; all successfully transmitted signals to staff pagers/devices and were able to be reset. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 74 F. [CONTINUED ON LIC 809]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

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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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 LAS CAMPANAS	FACILITY NUMBER: 374600488
	VISIT DATE: 02/13/2025

NARRATIVE

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[CONTINUED FROM LIC 809]

Where tested, hot water temperature at taps accessible to residents were all compliant: Bedroom #1 Sink was 112.5 F, Bedroom #15 Sink was 113.4 F, Bedroom #17 Sink was 112.1 F, Bedroom #475 Sink was 111.2 F, Bedroom #482 Sink was 109.6 F, Bedroom #485 Sink was 111.6 F, and Bedroom #488 Sink was 112.1 F. Appliances to preserve perishable food were also all compliant in temperature: Main Kitchen Walk-In Refrigerators were 40 F or colder, and Main Kitchen Walk-In Freezers were 0 F or colder. Assisted Living, Memory Care, and Medication Room Refrigerators and Freezers were also complaint in temperature. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Plenty of cooking and dining equipment and utensils were present.

There were no sharp objects, toxic chemicals/poisons, active fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. The facility’s swimming pools were secured behind locked fences and gates, consistent with regulation. Per the Licensee, no firearms or ammunition are kept at the facility. Fire detection system, carbon monoxide detectors, nighttime lighting, emergency lighting, and facility telephone were all working. The facility’s fire extinguishers were serviced within the last twelve (12) months. Required licensing postings were observed in visible areas of the facility. Fire/disaster drills were performed at required intervals. There were reserve supplies of Personal Protective Equipment (PPE) and staff had been trained on PPE within the last twelve (12) months. Licensee presented proof of current business liability insurance.

No deficiencies were cited during this annual inspection. However, LPA issued one (1) Technical Violation (TV) regarding adding three (3) more stairwell evacuation chairs (refer to the LIC9102-TA page); the facility presently has sixteen (16) of these chairs.

An exit interview was conducted with Shila Jurado, to whom a copy of this report, the LIC9102-TV page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC809 (FAS) - (06/04)

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