<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600661
Report Date: 10/10/2023
Date Signed: 10/11/2023 09:03:01 AM


Document Has Been Signed on 10/11/2023 09:03 AM - 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: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:
10/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Caregiver Salvacion ManaguitTIME COMPLETED:
12:00 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) Debbie Correia conducted a case management visit to cite for a deficiency derived from a prior complaint. LPA met with Caregiver Managuit, and discussed the purpose of the visit.

During a complaint investigation it was discovered there was a reportable incident that occurred and based on a facility records review the incident had not been reported to Community Care Licensing (CCL) and the time surpassed that is allowed to report to CCL to meet reporting requirement mandate.

Deficiency is being cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D.

An exit interview was conducted, and this report was discussed with the Caregiver Managuit. A copy of the report, LIC 809-D, and Licensee/Appeal Rights (LIC 9058 01/16) will be emailed to the Licensee following the visit. Acknowledgement of receipt of the documents is requested upon receipt.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
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 2


Document Has Been Signed on 10/11/2023 09:03 AM - 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: CALIFORNIA HOME FOR SENIORS
FACILITY NUMBER: 374600661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2023
Section Cited
CCR
87211(a)

1
2
3
4
5
6
7
(a) Each licensee shall furnish to the licensing agency such reports as (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Caregiver Managuit and Licensee Quillope will seek a CCL certified vendor to conduct a training on reporting requirements.

Proof of completion will be proved to CCL by POC due date.
8
9
10
11
12
13
14
Based on resident interviews, LPA observations, and a records review, the Licensee did not report an incident per CCL reporting requirements.

This poses a potential health risk to one (1) out of 14 residents.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2