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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600508
Report Date: 07/02/2024
Date Signed: 07/02/2024 05:05:08 PM

Document Has Been Signed on 07/02/2024 05:05 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:VELASCO HOME IIIFACILITY NUMBER:
374600508
ADMINISTRATOR/
DIRECTOR:		ELIZABETH VELASCOFACILITY TYPE:
735
ADDRESS:1549 GRAND TETON COURTTELEPHONE:
(619) 691-0761
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 5DATE:
07/02/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Caregivers Romy Pino and Gloria Laroza, and Administrator Elizabeth VelascoTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to continue a Required Annual Inspection which began on 06-25-2024. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregivers Romy Pino and Gloria Laroza. LPA also spoke with Administrator Elizabeth Velasco via phone during the visit.

During the inspection, LPA, accompanied by Licensee’s staff, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was complaint at 73 F. Hot water temperature at taps accessible to clients were also compliant: Kitchen Sink was 105.8 F, Bathroom #1 Sink was 106.2 F, and Bathroom #2 Sink was 105.6 F. Appliances to preserve perishable food were also compliant in temperature: Kitchen Refrigerator was 35 F and Kitchen Freezer was 0 F. The Garage Freezer was 0 F. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present.

The facility did not feature a secured perimeter or delayed egress doors. There were no active fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. No pools or bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguisher was serviced within the last twelve (12) months.

[CONTINUED ON LIC 809-C, 1 of 3]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 11
Document Has Been Signed on 07/02/2024 05:05 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/02/2024 at 11:11 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: VELASCO HOME III
FACILITY NUMBER: 374600508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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
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Based on LPA observation, Licensee did not ensure that a cleaning solution and other items, which could pose a danger if readily available to clients, were stored where inaccessible to 5 of 5 clients (C1 through C5). This posed an immediate health and safety risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
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During LPA's site visit, facility staff locked away the cleaning solution and other items described, resolving the immediate risk. Going forward, Licensee agreed to remind staff to secure these items behind a lock when said items are not actively being used. The Plan of Correction is satisfied.
Type A
Section Cited
CCR
80010(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, regarding 1 of 5 clients (C1), Licensee operated the facilty beyond the conditions and limitations specified on the license. This posed an immediate safety risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Per records and staff interviews, C1 was previously non-ambulatory status, but starting with their May 2022 LIC602 Physician's Report, their doctor determined C1 was bedridden. Multiple staff interviews suggest that C1 is currently able to turn and reposition themselves in bed. During today's visit, Licensee contacted C1's physician to request an updated LIC602 Physician's Report to be completed on C1, resolving the immediate risk. If Licensee subsequently obtains an updated LIC602 for C1 showing they are not bedridden, Licensee agreed to E-mail a copy of this doucment to LPA as soon as received, but no later than 08/02/2024. If C1's physician insists that C1 is indeed bedridden, Licensee agreed to immediately issue a 30-day eviction notice to C1, their San Diego Regional Center (SDRC) coordinator, the Long Term Care Ombudsman, and CCLD.
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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 07/02/2024 05:05 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/02/2024 at 11:11 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: VELASCO HOME III
FACILITY NUMBER: 374600508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1522(c)(1)
General Provisions
(c)(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, residence, or initial presence in the facility. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed and staff interviews, Licensee did not ensure that 1 of 5 staff (S1), who was not exempted, obtained the required criminal record clearance or exemption prior to employement at the facility. This posed an immediate safety risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
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LPA review of the Guardian datebase shows that S1 had commenced the background clearance process, but had not yet finished it. Licensee agreed during today's visit that they will not allow/assign S1 to work any more days at the facility until S1 successfully completes their background clearance process. This action resolves the deficiency. The Plan of Correction is satisfied.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 07/02/2024 05:05 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/02/2024 at 11:11 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: VELASCO HOME III
FACILITY NUMBER: 374600508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85075.4(a)
Observation of the Client
(a) The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and staff interview: The Licensee did not regularly observe 3 of 5 clients (C1, C2, and C3) for changes in physical functioning, specifically weight gain/loss. This posed a potential health risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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For all five clients currently in care (C1 through C5), Licensee agreed to obtain current (i.e., July 2024) body weights and record them in these clients' Weight Logs in their binders. Licensee agreed to E-mail LPA these logs, by the POC due date. Going forward, Licensee agreed to have its staff weigh each client once per month, and to report any unusual changes in weight to the client’s physician, responsible person (if applicable), and San Diego Regional Center (SDRC) Coordinator.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and staff interview: For 1 of 5 staff (S1), Licensee did not ensure that a personnel record was maintained on this employee.
POC Due Date: 08/02/2024
Plan of Correction
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Per administrator interview, Licensee no longer plans to employ S1 at the facility. Therefore, a personnel file is no longer required for S1, and the Plan of Correction is satisfied. In the event Licensee later decides to employ S1, Licensee agrees to maintain a personnel file on S1, complete with: a) LIC501 Personnel Record, b) LIC508 Criminal Record Statement, c) Documenation of successful criminal record clearance, d) LIC503 Health Screening Report with negative Tuberculosis test result.
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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 07/02/2024 05:05 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/02/2024 at 11:11 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: VELASCO HOME III
FACILITY NUMBER: 374600508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)(4)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (4) Assistance with prescribed medications which are self-administered.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records and interviews, Licensee did not ensure that all its personnel had training/skill in assisting clients with prescribed self-administered medications, which could also be evidenced by safe and effective job performance. This posed a potential health and safety risk to 5 of 5 clients (C1 through C5) in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee agreed to coordinate with its contracted pharmacy to send all current direct care staff and facility administrator to the pharmacy’s training course/class for medication-passers. Licensee agreed to send copies of these class completion certificates to LPA, by the POC due date. Going forward, Licensee agreed to ensure any newly hired caregiver completes this pharmacy-led course, before allowing that staff to pass medications independently. Licensee also agreed to file the medicaiton training certificates in the personnel binders.
Type B
Section Cited
CCR
80072(a)(8)(B)
Personal Rights
(B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interviews: For 2 of 5 clients (C1 and C2), who each used a Postural Support, Licensee did not obtain, and maintain in the client’s record of care, a written order from the client’s physician indicating the need for the postural support. This posed a potential personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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For C1 and C2, Licensee agreed to contact their respective physicians to obtain a written order saying a wheelchair seatbelt is needed by the client. For C2, Licensee agreed to also obtain a written order from their physician saying the support brace/strap is needed by the client. Licensee agreed to E-mail these orders for C1 and C2 to LPA, by the POC due date. Licensee agred that should a physician decline to write an order for any such device, they will immediately cease using it for that specific client, and to E-mail LPA notifying him of such.
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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 07/02/2024 05:05 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/02/2024 at 11:11 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: VELASCO HOME III
FACILITY NUMBER: 374600508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and staff interview: Licensee did not maintain a written Functional Capabilities Assessment for 5 of 5 clients (C1 through C5). This posed a potential health and safety risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee agreed to complete an LIC9172 Funtional Capabilties Assessment (or equivalent document) for C1 through C5, and to E-mail copies of these to LPA, by the POC due date. Licensee agreed to file these in the clients' care binders, and to update them as needed (i.e., upon change in condition) for all current and future clients.
Type B
Section Cited
CCR
80092.1(k)(2)
General Requirements for Restricted Health Conditions
(k) If the licensed health professional delegates routine care, the following requirements must be met for health conditions specified in Sections 80092.3, 80092.4 and 80092.6 through 80092.11: (2) The licensee ensures that the licensed professional reviews staff performance as often as necessary, but at least annually.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and staff interview: 1 of 5 clients in care (C1) had a restricted health condition (gastronomy). For 5 of 5 staff (S1 through S5), Licensee did not ensure that a licensed professional reviewed these persons' care performance on the restricted health condition at least annually. This posed a potential health risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee agreed to have its contracted Registered Nurse (RN) train all its existing staff on gastronmy care (to include a skills verification exam/demonstration for each staff). Licensee agreed to E-mail the training sign-in sheet/documentation to LPA, by the POC due date.
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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 07/02/2024 05:05 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/02/2024 at 11:11 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: VELASCO HOME III
FACILITY NUMBER: 374600508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on records review and manager interview: Licensee did not conduct an emergency/disaster drill at least quarterly for each shift. This posed a potential safety risk for 5 of 5 clients (C1 through C5) in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee agreed to perform two (2) emergency/disaster drills [one of which will be on the morning (AM) shift (6:00 AM to 2:00 PM), and one of which will be on the overnight (NOC) shift (i.e., 10:00 PM to 6:00 AM)], and to document the results of the drills in writing. Licensee agreed to E-mail proof of drill completion, by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 07/03/2024 11:28 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/03/2024 11:26 AM


Created By: Dang Nguyen On 07/02/2024 at 12:37 PM
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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VELASCO HOME III
FACILITY NUMBER: 374600508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)

80075 Health Related Services: “(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.” This requirement was not met, as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record reviewed and staff interviews, Licensee did not ensure that 2 of 5 clients (C1 and C3) were assisted as needed with self-administration of prescription medications. This posed a potential health risk to persons in care.
POC Due Date: 07/16/2024
Plan of Correction
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2
3
4
For C1, Licensee agreed to immediately contact their physician to inform them that C1 has not been receiving their routine Oyster Calcium 500 mg tablet and their Mupripocin 2% topical medication, due to pharmacy not dispensing these medications to the facility. For C3, Licensee agreed to immediately contact their physician to inform them that C3 has not been receiving their routine Lorazepam 1mg tablet, due to pharmacy not dispensing this medication to the facility. By the POC due date, Licensee agreed to E-mail LPA either: a) photos of the medicine containers blister packs present at the facility; or, alternatively, b) proof that these specific medication orders have been discontinued by the physician.
Type B
Section Cited
CCR
80075(b)(5)
80075 Health Related Services: “(b)(5)...facility staff designated by the licensee shall be permitted to assist the client with self-administration, providing all the following requirements are met: (C) A record of each dose is maintained in the client’s record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client’s response.”
Deficient Practice Statement
1
2
3
4
This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 5 clients (C4), Licensee did not record in the client’s record the date, time, dosage, and client’s response to PRN dose(s) which were given to them. This posed a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
1
2
3
4
Licensee agreed to coordinate with its contracted pharmacy to send all current direct care staff and facility administrator to the pharmacy’s training course/class for medication-passers. Licensee agreed to send copies of these class completion certificates to LPA, by the POC due date. Going forward, Licensee agreed to ensure any newly hired caregiver completes this pharmacy-led course, before allowing that staff to pass medications independently. Licensee also agreed to file the medicaiton training certificates in the personnel binders.
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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
Page: 8 of 11
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: VELASCO HOME III
FACILITY NUMBER: 374600508
VISIT DATE: 07/02/2024
NARRATIVE
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[CONTINUED FROM LIC 809] A complete first aid kit was present and readily accessible. Required licensing postings were observed in visible areas of the facility. Licensee also presented proof of current/active business liability insurance and surety bond, both in the required face amounts.

During the tour, LPA observed hazardous items unsecured/accessible to clients in care: In the facility’s living room were two (2) metal screwdrivers. In the facility’s backyard, there was a gallon of cleaning chemical and a long-handled gardening rake with pointed metal tines. (Facility staff subsequently locked away these items during LPA’s visit).

LPA reviewed multiple client and staff records. LPA also interviewed staff who were present and those clients who were able to speak. Staff interviews aligned to show Staff #1 (S1) worked two (2) shifts at the facility, on 06/22/2024 and 06/23/2024, respectively. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] However, Licensee did not maintain a personnel record/file on S1, as was required. Also, a review of CCLD’s Guardian and Licensing Information System (LIS) databases showed that S1 had not completed the required criminal background clearance process prior to working.

According to the facility’s license and approved fire clearance, the facility has a maximum capacity for six (6) clients, of whom all may be ambulatory or non-ambulatory, but none (0) may be bedridden. According to each client’s latest LIC602 Physician’s Reports: There were a total of five (5) clients in care, of which three (3) were ambulatory, one (1) was non-ambulatory, and one (1) was bedridden. LPA observed and staff interviews confirmed that the bedridden person, Client #1 (C1), also required a Hoyer-lift machine to transfer from bed to wheelchair, and vice versa. LPA observed, and records and interviews confirmed, that C1 had a gastronomy device (“G-Tube”), which is defined in regulation as a “Restricted Health Condition.” While Licensee did possess a prior approved Waiver Request (from CCLD) and a Restricted Health Condition Care Plan for C1’s gastronomy, interviews and records showed that since this plan’s development in 2008, a licensed professional had not reviewed the direct care staffs’ performance on caring for this condition at least once per year, as was required. Furthermore, C1 and Client #2 (C2) both used wheelchair seat belts. C2 also wore a special strap brace to help them maintain upright body posture. However, Licensee did not maintain on file written orders from the physicians indicating these clients’ need for their respective postural supports, as was required.

[CONTINUED ON LIC 809-C, 2 of 3]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
Page: 9 of 11
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: VELASCO HOME III
FACILITY NUMBER: 374600508
VISIT DATE: 07/02/2024
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 3]

Licensee did not complete and maintain the required written Functional Capabilities Assessment for any of the five (5) clients in care. Also, it had been over five (5) months since Licensee last measured C1’s body weight, and over eight (8) months since Licensee last weighed C2 and Client #3 (C3). (Regulation required Licensee to regularly observe clients, to include changes in body weight.)

Review of the facility’s Medication Administration Records (MARs) for the current pharmacy cycle (i.e. 06-11-2024 through 07-02-2024) showed: C1 had not once received two (2) of their prescribed daily routine medications during the review period, and C3 had not once received one (1) of their prescribed daily routine medications. (There were no indications from staff interviews that either C1 or C3 had suffered any observable negative health symptom as a result.) Interviews of line staff unanimously corroborated that C1 and C3 were supposed to be taking these medications, that the refills had not arrived from the pharmacy, that facility management was made aware of these issues, and that it had been around two (2) months since C1 and C3 last received these absent medications. The MAR for Client #4 (C4) also showed that on 06-13-2024, facility staff gave C4 two (2) of their prescribed as-needed (PRN) medications. However, they did not document the specific time/hour these PRNs were given or C4’s response to the doses, as was required. Interviews of staff showed that they were not aware that it was necessary to document the times PRNs are given, or the client’s response to them. According to the caregivers interviewed, it had been more than five (5) years since they personally received training in medication assistance. According to the facility’s training records, staff were in-serviced on “Decreasing Medication Errors” in 2007.

Records review and interviews further showed that while Licensee performed emergency/disaster drills at least quarterly, they occurred only on the PM (afternoon) shift. It had been over one (1) year since a documented drill occurred on the AM (morning shift), and over two (2) years since a documented drill occurred on the NOC (overnight) shift.


[CONTINUED ON LIC 809-C, 3 of 3]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
Page: 10 of 11
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: VELASCO HOME III
FACILITY NUMBER: 374600508
VISIT DATE: 07/02/2024
NARRATIVE
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[CONTINUED FROM LIC 809-C, 2 of 3]

Twelve (12) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. Since one of the deficiencies was related to the facility operating beyond its prior-approved fire clearance, an Immediate Civil Penalty of $500 was assessed (see the LIC421-IM page). Since one of the deficiencies was related to an employee working on two (2) days at the facility without background clearance, a Civil Penalty of $200 was also assessed (see the LIC421-BG page).

LPA also issued Technical Assistance (TA) regarding staff auditory alert devices on facility exit doors, regarding facility sketch / evacuation procedures, and regarding alternate shelter locations during a disaster (refer to the attached LIC 9102-TA pages).

An exit interview was conducted with Velasco, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TA pages, the LIC421-IM page, the LIC421-BG page, the LIC811 Confidential Names List, 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: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
Page: 11 of 11