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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601035
Report Date: 12/04/2023
Date Signed: 12/04/2023 02:24:23 PM

Document Has Been Signed on 12/04/2023 02:24 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:LUCY'S PLACEFACILITY NUMBER:
374601035
ADMINISTRATOR:LUCIA B.TOTANESFACILITY TYPE:
740
ADDRESS:4770 ELM TREE DRIVETELEPHONE:
(760) 806-3873
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY: 6CENSUS: 4DATE:
12/04/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Caregiver Victoria DaoTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Plan of Correction (POC) visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Caregiver Victoria Dao.

The purpose of today's visit was to verify if deficiencies cited on 11/8/2023 had been corrected. On 11/8/2023, the licensee was issued 2 deficiencies with a correction date of 11/22/2023. On 11/27/23, LPA Ruiz conducted a POC visit and issued two $500 civil penalties for failure to correct deficiencies, totalling $1,000.

During today's visit, LPA observed residents in care and spoke with staff. Caregiver Dao provided LPA Ruiz with proof of medication training completed on 11/27/2023. During a visit on 11/27/2023, LPA Ruiz observed resident medications were centrally stored and in their original container. Therefore, deficiency 87465(h)(5) has been cleared as of 11/27/23. No further civil penalties have been issued for this deficiency.

Caregiver Dao stated that she has not been able to update and complete resident records. Therefore, deficiency 87506(a) remains uncorrected as of today's date. An additional immediate civil penalty of $100 per day for 7 days totaling $700 is being assessed for failure to correct for the time period of 11/28/2023 through 12/4/2023 and will be ongoing until corrected.

An exit interview was conducted with Caregiver Victoria Dao, whose signature below confirms receipt of a copy of this report, an LIC421FC, and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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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