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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600732
Report Date: 05/29/2024
Date Signed: 05/29/2024 04:55:47 PM


Document Has Been Signed on 05/29/2024 04:55 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
SO. CAL AC/SC, 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:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Leonor Carmona, Licensee/AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Constancia Monar, Caregiver. Licensee/Administrator, Leonor Carmona later joined LPA.

According to the facility’s license, the facility has a maximum capacity of six (6) residents, all of whom may be non-ambulatory. On the day of the visit, six (6) residents, two (2) caregivers and one (1) independent tenant were present. LPA verified that staff and independent person received background clearances.

LPA toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. Medications were labeled, as required, and stored in locked areas.

No pool or bodies of water are present. Per Ms. Carmona, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. The staff and reviewed files which LPA reviewed contained required documents. Confidential records were stored in locked areas.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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 05/29/2024 04:55 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: CARMONA'S RESIDENTIAL CARE
FACILITY NUMBER: 374600732

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, staff and outside source interviews and record review, the licensee did not comply with the section cited above in one out of six residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee agreed to arrange the relocation of a bedridden resident to a facility providing adequate level of care and appropriate fire clearance. Licensee to provide CCLD with facility address, telephone number and contact person by POC due date.
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in one of six persons (R1) which posed an immediate safety risk to persons in care. An immediate civil penalty in the amount of $500 was assessed during today's visit.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee agreed to arrange the relocation of a bedridden resident to a facility providing adequate level of care and appropriate fire clearance. Licensee to provide CCLD with facility address, telephone number and contact person. Licensee understands additional civil penalties may be assessed if POC not completed as agreed.
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: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CARMONA'S RESIDENTIAL CARE
FACILITY NUMBER: 374600732
VISIT DATE: 05/29/2024
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Deficiencies were cited per California Code of Regulations, Title 22 (See LIC809-D), which resulted in assessment of an immediate Civil Penalty of $500.00 and thus charged and noted on the attached LIC421-IM.

An exit interview was conducted with Ms. Carmona, to whom a copy of this report, the LIC809-D page, LIC421-IM, and Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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