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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600860
Report Date: 10/16/2024
Date Signed: 10/16/2024 11:46:23 AM


Document Has Been Signed on 10/16/2024 11:46 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:PINE VALLEY HOME CAREFACILITY NUMBER:
374600860
ADMINISTRATOR:DOMILOS, NORISAFACILITY TYPE:
740
ADDRESS:1530 MONTE VISTA DRIVETELEPHONE:
(760) 630-6381
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 1DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:ADMINISTRATOR, NORISA DOMILOSTIME COMPLETED:
11:55 AM
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On October 16, 2024, Licensing Program Analyst (LPA), Venus Mixson, made an unannounced visit to the facility for the purpose of conducting the Required Annual inspection, and met with Norisa Domilos, the Administrator. LPA introduced herself and stated the purpose for the visit. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site.

PHYSICAL PLANT: Facility is located at 1930 Monte Vista Drive, Vista, CA. 92084, and the land line phone number is (760) 630-6381 and is operable. Facility is licensed for six Elderly Adults for a (740) facility type and is operating at one which is within the conditions and limitations of the license. Outdoor and indoor passageways are free of obstruction and debris at the time of this visit. There were no pools or bodies of water observed on the property at this time. According to staff, there are no known weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to resident in care. The facility temperature was within in regulations for this time of day and the season, and there was sufficient lighting throughout the facility.

Hot Water temperature: Was tested and found to be within regulations. LPA Mixson observed the Fire extinguisher located at the front door area, located off the kitchen, and has proper inspection tag. Last inspected by Fire Tech. The smoke and carbon monoxide alarms were in the green. The interior and exterior areas of the home were observed to be clean and organized.

FOOD SERVICE: There was a variety of food types which were sealed and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient for the number of residents in care. The kitchen was observed to be clean, neat, and orderly. Additionally, kitchen was free of orders and any signs of pest. LPA observed the required two-day supply of perishable and seven-day supply of non-perishable food items.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PINE VALLEY HOME CARE
FACILITY NUMBER: 374600860
VISIT DATE: 10/16/2024
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Care & Supervision/Administration: Adequate staff are present for the supervision of resident in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses an administrator’s certificate with an expiration date of 11/10/2023, and renewal application and funds were sent sometime in September of 2023.

Records Reviewed and Resident/Staff Files: LPA reviewed two staff files and reviewed the facility's staff schedule. The staff file reviewed has criminal clearance and updated training's along with First Aid and CPR Certification. One resident file was reviewed and possessed required paperwork, except for the emergency identification information and current doctors’ appointments and weight records, obtained on the Physicians report LIC 602.



MEDICATION: Medications were reviewed for one resident in care. Medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, and inaccessible to resident in care. Medications and medication documentation was observed to be well organized and monitored.

Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan. Additionally, the disaster training binder and other training's were reviewed. LPA observed the last fire drill met the department standards and was conducted on 10/01/2024 and was conducted by Administrator.

Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found required infection control measures. There were TA deficiencies observed for missing forms in one of one residents file and TA per Title 22, Division 6 of the California Code of Regulations at this time.



An exit interview was conducted where a copy of this report was discussed and given to Administrator, Norisa Domilos.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/16/2024 11:46 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: PINE VALLEY HOME CARE
FACILITY NUMBER: 374600860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)

Medical Assessment prior to a person's acceptance as a resident, the licensee shall ontain and keep on file, documentation of a medical assessment, signed by a physician made within the last year. The Licensee shall permitt the use of form LIC 602, Physicianls report to obtaine the medicla assessment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record reviews the licensee did not comply with the section cited above in [1] out of [1] [Reisdents files] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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THE ADMINISTRATOR INFORMED LPA AND STATED THEY WOULD MAKE THE RESIDENT A DOCTORS APPOINTMENT BY THE DATE LISTED ABOVE AND EMAIL OR FAX THE COMPLETED AND SIGNED FORMS TO THE RO BY THE LISTED DATE.
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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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