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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600732
Report Date: 01/17/2023
Date Signed: 01/17/2023 03:50:33 PM


Document Has Been Signed on 01/17/2023 03:50 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:CARMONA'S RESIDENTIAL CAREFACILITY NUMBER:
374600732
ADMINISTRATOR:MARY ANNE MARTINEZFACILITY TYPE:
740
ADDRESS:3427 BEAGLE PLACETELEPHONE:
(858) 277-6731
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY:6CENSUS: 6DATE:
01/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Caregiver Milagros "Mila" CaganapTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to deliver an unrelated deficiency related to a complaint investigation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Milagros "Mila" Caganap. LPA spoke to Licensee Leonor Carmona via phone during the visit.

During a complaint investigation, interviews with outside sources and records review revealed that staff did not administer medication as prescribed. Interviews revealed that facility staff were not administering a resident's sedative medications as prescribed due to staff concerns that the resident would be overly sedated. Hospice staff provided staff with education regarding administering medication as prescribed in October 2021. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Caregiver Mila Caganap and Licensee Leonor Carmona via phone, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
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 01/17/2023 03:50 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: CARMONA'S RESIDENTIAL CARE
FACILITY NUMBER: 374600732

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2023
Section Cited

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87465 Incident Medical and Dental Care (c)... facility staff designated by the licensee shall be permitted to assist the resident with self-administration... (2) Once ordered by the physician the medication is given according to the physician’s directions.
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Licensee stated that she will conduct an in-service training regarding medication administration and will provide staff sign-in sheet to the Department by POC due date.
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This requirement has not been met as evidenced by: Based on interviews and records review, the Licensee did not ensure that staff administered medication as prescribed for R1. This poses a potential health risk to 6 of 6 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2