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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600661
Report Date: 04/19/2024
Date Signed: 04/21/2024 06:25:56 PM


Document Has Been Signed on 04/21/2024 06:25 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:
04/19/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Assistant Administrator Silvana HuertaTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced visit to continue a Required Annual Inspection which began on 04/16/2024. An Annual Inspection visit was also conducted on 04/18/24. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Assistant Administrator Silvana Huerta.

According to the facility’s license, the facility has a maximum capacity of fifteen (15) non-ambulatory residents, ages 60 and above. There is a Hospice Waiver for four (4) residents. During today’s inspection, there were a total of fourteen (14) residents in care, of which 6 are non-ambulatory. This facility does feature a secured perimeter.

LPA interviewed staff and residents and reviewed multiple staff and resident records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. The Administrator also presented proof of current/active business liability insurance.

No pools or bodies of water were observed on the premises. Per Silvana Huerta, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 70 F. (continued on next page, LIC 809 C)
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
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 04/21/2024 06:25 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
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: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)(2)(B)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (B) Walls and window coverings in resident care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation on 04/18/24, the licensee did not comply with the section cited above in 2 bedrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2024
Plan of Correction
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Assistant Admnistrator indicated that a deep cleaning will be conducted and blinds will be replaced in all bedrooms by POC due date.
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 1 out of 7 bedrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2024
Plan of Correction
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Assistant Administrator purchased new non-skid mats for all bathrooms on 04/18/24. Administrator will email the receipt to LPA.
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: Denise PowellTELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/21/2024 06:25 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
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: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2024
Plan of Correction
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Assistant Administrator indicated that cupboards are currently being cleaned by staff. Pest control services have been hired. A company has also been hired to do a deep cleaning of the kitchen.
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: Denise PowellTELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
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: CALIFORNIA HOME FOR SENIORS
FACILITY NUMBER: 374600661
VISIT DATE: 04/19/2024
NARRATIVE
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Hot water temperature at taps accessible to residents were all compliant: Bathroom #1 sink was 110.8 F, Bathroom #2 sink was 112 F, Bathroom #3 was 120 F. Bathroom #4 is used by staff only. LPA, accompanied by the Administrator, toured the interior and exterior of the facility, and inspected each room. 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.

Upon inspection of the bedrooms, LPA observed that blinds, windowsills, window shades and walls in various bedrooms had dirt, layers of dust and cobwebs. The rooms require dusting and cleaning. LPA also observed that the bathroom shower in bedroom #5 (B5), which is used by residents, had not been cleaned and was missing a non-skid mat/skid strips. The bathroom in B5 also had two tiles falling from the walls.



During the walk through inspection, LPA also observed that Staff #1 (S1) was sleeping during break time inside resident bedroom #4 (B4), while Resident #1 was in the room. B4 is currently being occupied by Resident #1 (R1). Interviews with Staff #2 (S2) on 04/16/24 and R1 on 04/18/24 revealed that staff were using R1’s bedroom as a break room.

There was at least 2 days of perishable food, and at least 7 days of non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. During the inspection of the kitchen, LPA observed that the kitchen cupboards contained dirt and dead insects.

Five (5) 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 Assistant Administrator.

An exit interview was conducted with Silvana, to whom a copy of this report, the LIC 809-D pages, the LIC 811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/21/2024 06:25 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: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307
87307 Personal Accommodations and Services: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.


This requirement is not met as evidenced by: Based on LPA observation, there are falling tiles in the bathroom in bedroom #5 which posed a potential health and personal rights risk to 4 out of 14 residents in care.
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2024
Plan of Correction
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Assistant Administrator indicated that a Handyman was hired 04/19/24 to fix the tiles in the bathroom. If the tiles cannot be fixed, they will be replaced.
Type B
Section Cited
CCR
87468.2
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations (...).


This requirement is not met as evidenced by: Based on LPA observations and interviews, Resident #1 (R1's) bedroom was being used as a staff room. Licensee did not ensure that Resident #1 (R1) was accorded privacy in their bedroom.
Deficient Practice Statement
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Based on LPA observations and interviews, the licensee did not comply with the section cited above in 1 out of 14 residents which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2024
Plan of Correction
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Assistant Administrator indicated that staff will be trained on personal rights of residents and also facility policies on proper room usage.
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: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
LIC809 (FAS) - (06/04)
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