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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600508
Report Date: 03/17/2025
Date Signed: 03/17/2025 02:15:50 PM

Document Has Been Signed on 03/17/2025 02:15 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
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: 4DATE:
03/17/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Caregiver Romy PinoTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Romy Pino.

Today's visit was in response to a third-party report of the death of Client #1 (C1), received at the CCLD San Diego Regional Office (RO) on 03/13/2025. [See LIC 811 Confidential Names List for a description of select client identifiers used in this report.] Per the report, C1 passed away on 03/12/2025 at the hospital.

During today’s visit, LPA performed a facility tour and welfare check on remaining clients, finding they were in good/stable health. LPA briefly spoke with the caregivers present, then collected copies of and reviewed pertinent care records on C1.

Upon LPA’s arrival, he observed staff using a gait belt to tie/immobilize one of the wheels of Client #2’s (C2’s) wheelchair. C2 appeared agitated to LPA. While Licensee possessed a CCLD Exception Request and a written doctor’s order for C2 to use a wheelchair seat belt for their personal safety (i.e., to keep them from falling out), Licensee was not authorized to immobilize C2’s wheelchair, the latter of which constituted a restraining device and a violation of C2’s personal rights. [Staff explained to LPA that they had tied C2’s wheel to prevent C2 from pushing their wheelchair into the wall and causing property damage. LPA directed staff to immediately untie the wheel, which they did. C2 later calmed down during LPA’s visit.] During the facility tour, LPA observed that the facility’s fire extinguisher had not been serviced within the last twelve (12) months, as was required to maintain ongoing compliance with the facility’s existing fire clearance.

[CONTINUED ON LIC 809-C, 1 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
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: VELASCO HOME III
FACILITY NUMBER: 374600508
VISIT DATE: 03/17/2025
NARRATIVE
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[CONTINUED FROM LIC 809]

Care records and caregiver statements together showed: When C1 first moved to the facility in 1995, they were able to walk independently, albeit awkwardly, due to their cerebral palsy. They were also on a regular texture diet and able to eat independently then, with no dysphagia indicated. During the second half of 2024, C1 had an observable decline in overall physical health, now needing total care with all activities of daily living (ADLs), to include two-person transfer with Hoyer-lift and one-on-one staff assistance with eating/feeding. Starting 08/19/2024, C1 required a pureed-texture diet. According to a 11/26/2024 nursing assessment, C1 was now diagnosed with “dysphagia, oropharyngeal phase” and needed their liquids/beverages to be nectar-thick consistency. San Diego Regional Center (SDRC) and nursing records showed C1 required hospital treatment on at least four (4) recent occasions (i.e., July 2024, August 2024, October 2024, and March 2025, respectively) for acute respiratory failure and/or aspiration pneumonia. Despite evidence of a significant change in C1’s physical and social condition, Licensee did not perform a written reappraisal/update of C1’s Needs and Services Plan to reflect their new care needs, or obtain an updated Medical Assessment on C1 from their physician to support this process.

Records review further showed: On 03/08/2025, facility staff called 9-1-1 and sent C1 to the hospital for abnormal breathing, where C1 was then admitted into the Intensive Care Unit (ICU) for treatment of aspiration pneumonia. C1’s condition continued to decline. C1’s conservator requested that C1 be placed on comfort care, and C1 passed away during the late evening 03/12/2025. On 03/13/2025, the conservator notified Licensee of C1’s death. During today’s site visit, LPA located drafted incident reports for the above events in C1’s care binder. However, prior to this visit, CCLD had no record of these reports from Licensee, nor did the RO have record of Licensee verbally reporting these latest incidents involving C1. Licensee was required to submit a written incident report to CCLD for C1’s hospitalization within seven (7) days of occurrence. Regarding both C1’s hospitalization and C1’s death, Licensee was required to provide at least verbal notification to the RO by the next business day for each event, respectively.


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

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
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: VELASCO HOME III
FACILITY NUMBER: 374600508
VISIT DATE: 03/17/2025
NARRATIVE
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[CONTINUED FROM LIC 812-C, 1 of 2]

Also, the RO prior received from Licensee a written incident report describing C1 being hospitalized on 07/20/2024 for “lethargic symptoms” and refusal to drink fluids, but Licensee did not provide follow-up to the RO to indicate that C1 was then treated for “acute respiratory failure,” which was referenced in C1’s subsequent nursing assessment. The RO also did not receive from Licensee a written incident report describing C1’s October 2024 hospitalization for mild hyponatremia and pneumonia, for which they required antibiotics and follow-up treatment at a skilled nursing facility, which was also referenced in C1’s subsequent nursing assessment.

Five (5) deficiencies were cited per California Code of Regulations, Title 22 (refer to the LIC809-D pages). Plans of Correction were jointly developed with the Licensee.

When LPA first arrived for today’s visit, facility staff phoned Administrator Elizabeth Velasco, who confirmed understanding that a case management visit was underway. Velasco was occupied and unable to speak long. LPA phoned Velasco near the end of today’s site visit, but she was still busy.

An exit interview was therefore conducted with Caregiver Romy Pino. A physical copy of this report, the LIC 809-D pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Pino during today’s visit. An electronic set of these same documents were E-mailed to Elizabeth Velasco.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/17/2025 02:15 PM - It Cannot Be Edited


Created By: Dang Nguyen On 03/17/2025 at 01:49 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VELASCO HOME III
FACILITY NUMBER: 374600508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2025
Section Cited
CCR
80072(a)(8)

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80072 Personal Rights: “(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (8) Not to be placed in any restraining device.” This requirement was not met, as evidenced by:
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During today’s visit, staff immediately untied and removed the gait belt from C2’s wheelchair wheel, resolving the immediate risk. Licensee agreed to retrain all current staff on client’s personal rights and correct interventions to take when clients display agitated behavior, and to E-mail the training sign-in sheet to LPA by 04/17/2025.
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Based on LPA observation and staff interviews, Licensee did not uphold the right of 1 of 4 clients (C2) to not be placed in any restraining device. This posed an immediate personal rights risk to persons in care.
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Type A
03/17/2025
Section Cited
CCR80020(a)

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80020 Fire Clearance: “(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshall.” This requirement was not met, as evidenced by:
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During today’s visit, Licensee agreed to call a professional vendor to make an appointment to have the facility’s fire extinguisher serviced, resolving the immediate risk. Upon completion of service, Licensee agreed to E-mail LPA a copy of the paid invoice plus a photograph of the updated service tag, as soon as completed.
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Based on LPA observation, Licensee did not maintain ongoing compliance with its prior-approved fire clearance, which posed an immediate safety risk to 4 of 4 clients (C2 through Client #5) 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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/17/2025 02:15 PM - It Cannot Be Edited


Created By: Dang Nguyen On 03/17/2025 at 01:52 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VELASCO HOME III
FACILITY NUMBER: 374600508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2025
Section Cited
CCR
85068.3(a)

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85068.3 Modifications to Needs and Services Plan: “(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, C1 has passed away. There is no longer a need to update any of C1’s care documents. No Plan of Correction was formed.
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Based on records review and staff statements, for 1 of 5 clients (C1), Licensee did not update their Needs and Services Plan to ensure its accuracy following a significant change in their physical and social functioning. This posed a potential health risk to persons in care.
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Type B
03/17/2025
Section Cited
CCR80061(b)(1)(E)

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80061 Reporting Requirements: “(b) Upon the occurrence, during the operation of the facility, of any of the events specified…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…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…which threatens the physical…health…of any client.”
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As of the date of deficiency issuance, CCLD is now aware of the incidents that occurred prior to C1’s death and obtained copies of additional written reports from Licensee during today’s visit. This resolved the deficiency. Licensee was advised that repeat violations of this regulation may result in civil penalties being assessed.
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Based on records review and staff statements, for 1 of 5 clients (C1), Licensee did not make a report to the licensing agency by the next working day, and follow up with a written report within seven days, regarding an incident which threatened their physical health. This posed a potential health risk to persons 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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 03/17/2025 02:15 PM - It Cannot Be Edited


Created By: Dang Nguyen On 03/17/2025 at 01:54 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VELASCO HOME III
FACILITY NUMBER: 374600508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2025
Section Cited
CCR
80061(b)(1)(A)

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80061 Reporting Requirements: “(b) Upon the occurrence, during the operation of the facility, of any of the events specified…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…shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (A) Death of any client from any cause.”
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As of the date of deficiency issuance, CCLD obtained from Licensee a copy of a written Death Report for C1. This resolved the deficiency. Licensee was advised that repeat violations of this regulation may result in civil penalties being assessed. Licensee agreed to contact C1’s conservator and obtain a copy of their official county death certificate, and to E-mail it to LPA as soon as it is obtained.
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Based on records review and staff statements, Licensee did not make a report to the licensing agency by the next working day regarding the death of 1 of 5 clients (C1). This posed a potential health and safety risk to persons 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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025


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