374600488-1-11-2024-08-AS-AROS-CZDVWE-20240111154750

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600488
Report Date: 01/11/2024
Date Signed: 01/11/2024 06:15:08 PM

Document Has Been Signed on 01/11/2024 06:15 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 DE LAS CAMPANAS		FACILITY NUMBER:	374600488
ADMINISTRATOR:	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: 485	DATE:	01/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Executive Director Kimberly Dominy and Director of Residential Continuing Care Shila Jurado		TIME COMPLETED:	03:50 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 Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Director of Residential Continuing Care Shila Jurado, identifying herself and stating the purpose of the inspection. This facility serves five hundred eighty-two (582) residents 60 and above; of which two hundred twenty seven (227) may be non-ambulatory. Twenty-seven (27) whom may be Dementia Residents in the delayed egress unit. Approved hospice waiver for twenty (20). A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. This a muti-story, muti-unit complex with memory care on the ground level of the ‘Sur” building. Facility does feature delayed egress doors or a locked perimeter in the memory care unit. There are 3 pools on site, of which two are located outdoors. All pools on site are only accessible by key. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. LPA reviewed fire clearance inspections documents as well as inspections logs for generators. First aid bag(s) were complete and readily accessible in all the medical rooms. Required licensing postings were observed in visible areas of the facility. PPE supplies are on site. Passageways were free from obstructions. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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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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: CASA DE LAS CAMPANAS	FACILITY NUMBER: 374600488
	VISIT DATE: 01/11/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Emergency food supplies were kept in a underground garage locked storage area. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room not assessable to residents. Centrally stored medications were properly stored and locked in cabinets. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions.

Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPA conducted a review of In-service training procedures. Transportation procedures are compliant.

There is designated gym area and several large activity rooms as well as gathering areas throughout the facility. At the time of visit, LPA observed one large group activities in which many residents in the memory care unit were participating. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

No deficiencies were issued at the time of visit.

An exit interview was conducted with Executive Director Kimberly Dominy to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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