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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600688
Report Date: 03/10/2022
Date Signed: 03/10/2022 05:48:53 PM


Document Has Been Signed on 03/10/2022 05:48 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:FAMILY-STYLE CARE IIFACILITY NUMBER:
374600688
ADMINISTRATOR:JOSEFINA HULSEYFACILITY TYPE:
740
ADDRESS:2847 MORNINGSIDE STREETTELEPHONE:
(619) 856-4868
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY:6CENSUS: 5DATE:
03/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:54 PM
MET WITH:Josefina Hulsey, LicenseeTIME COMPLETED:
02:17 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dawn Segura conducted a case management visit to cite for a deficiency observed during a pre-licensing visit. LPA met with Josefina Hulsey, Licensee, and discussed the purpose of the visit.

While conducting a pre-licensing inspection visit, LPA measured and observed hot water temperature to be 102.4 and 142.6 degrees F in two bathrooms used by residents. After water heaters were adjusted, later during the visit, LPA checked the hot water temperatures again, and the hot water temperatures measured at 121.6 and 138.6 degrees F, respectively. During the visit, signs were posted in resident bathrooms warning of the high hot water temperatures.

A deficiency is being cited pursuant to 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 licensee. 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: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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 03/10/2022 05:48 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: FAMILY-STYLE CARE II
FACILITY NUMBER: 374600688

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2022
Section Cited

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Maintenance and Operation. Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105
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degree F and not more than 120 degree F. This requirement was not met as evidenced by: Based upon LPA observation, water temperature in resident bathrooms measured by LPA were 102.4 and 142.6 degrees Fahrenheit. This poses an immediate safety risk to 5 of 5 residents in care.
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Licensee will contact a plumber for an evaluation and inform Community Care Licensing (CCL) of the date of that visit by 3/11/2022 and offered to measure the temperature daily for the next 14 days and keep a temperature log to be forwarded to CCL by 3/30/2022.

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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: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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