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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600661
Report Date: 08/20/2024
Date Signed: 08/30/2024 12:44:06 PM


Document Has Been Signed on 08/30/2024 12:44 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:CALIFORNIA HOME FOR SENIORSFACILITY NUMBER:
374600661
ADMINISTRATOR:GLORIA S. QUILLOPEFACILITY TYPE:
740
ADDRESS:1061 E. BRADLEY AVENUETELEPHONE:
(619) 448-2870
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY:15CENSUS: 14DATE:
08/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Caregiver Eleanor WeberTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced follow up case management visit regarding a self-reported incident. LPA identified herself and explained the purpose of the visit to Caregiver Eleanor Weber. Eleanor allowed LPA entrance into the facility.

On 08/12/24, the Department received a self-reported incident report that described that on 08/11/2024, Resident #1 (R1) had eloped from the facility without staff supervision and returned the same day. During a case management visit on 08/14/24, LPA conducted a health and safety check, observed residents in care, reviewed records, and interviewed staff.

A review of R1’s medical report dated 03/19/24 revealed that R1 has dementia and is not able to leave the facility unassisted. A review of R1’s Care Plan dated 02/19/24 also revealed that R1 has wandering behaviors and “wanders outside in addition to wandering in residence; may or may not leave grounds.” Department interviews conducted with staff on 08/14/24 also revealed that R1 wanders around the inside of the facility, and in the backyard of the facility on a daily basis. A review of video camera footage from 08/11/24 also revealed that R1 walked outside the front door while staff and residents were in the dining room eating dinner. A records review revealed that there was no Absentee Notification Plan for R1, however, when R1 eloped, staff immediately called law enforcement and R1 was found at a local store and brought back to the facility. The Administrators are currently interviewing for a new 1 on 1 care staff for R1 and are in the process of purchasing an alarm system for the front door.

LPA provided Administrator Liza Mesdjian with technical assistance, regarding Absentee Notification Plans on an LIC9102TA form. One (1) deficiency was cited per California Health & Safety Code (HSC) (refer to the attached LIC 809-D).



A Plan of Correction was jointly developed with Administrator Liza Mesdjian via phone.
An exit interview was conducted with Eleanor, whose signature below confirms receipt of a copy of this report, LIC 809-D page and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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 08/30/2024 12:44 PM - 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: CALIFORNIA HOME FOR SENIORS
FACILITY NUMBER: 374600661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2024
Section Cited
HSC
1569.312(d)

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HSC 1569.312(d) Basic services requirements. Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by:
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Administrators conducted an in-service training with staff regarding the required supervision of R1 at all times. They are also purchasing a front door alarm system and are in the process of hiring a 1 on 1 caregiver for R1. They will submit proof of training and purchase of alarm system by 09/03/24.
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Based on interviews and record review, R1 eloped. The licensee did not ensure supervision was provided to 1 out of 13 residents [R1], which posed a potential health and safety risk to residents 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: Jennifer LottTELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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