374601035-11-8-2023-08-AS-RARZ-CXE2NQ-20231108163308

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601035
Report Date: 11/08/2023
Date Signed: 11/08/2023 04:33:16 PM

Document Has Been Signed on 11/08/2023 04:33 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 PLACE		FACILITY NUMBER:	374601035
ADMINISTRATOR:	LUCIA B.TOTANES		FACILITY TYPE:	740
ADDRESS:	4770 ELM TREE DRIVE		TELEPHONE:	(760) 806-3873
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92056
CAPACITY:	6	CENSUS: 4	DATE:	11/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator Lucia Totanes		TIME COMPLETED:	04:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Administrator Lucia Totanes. The facility is licensed for a maximum capacity of 6 residents, all of which may be non-ambulatory. The facility has a waiver for 4 hospice residents. During today’s visit, the facility had a census of 4 residents, 2 of which were non-ambulatory. The facility does not have a clearance for delayed egress or secured perimeter and LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Lucia Totanes and their certificate renewal was received by the Department as of 7/3/2023. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed near or on the premises. According to the Administrator, no firearms or weapons are stored on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 115.0 degrees Fahrenheit in a private resident bathroom and 116.4 degrees Fahrenheit in a common resident bathroom. The facility’s internal temperature was measured at 75 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. LPA also observed locked storage for resident medications and resident and staff files. 4 resident medications were observed to be stored in pillboxes with multiple days prepared. LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 40 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance and were associated to the facility. Continued on LIC809-C page...

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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 6

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: LUCY'S PLACE	FACILITY NUMBER: 374601035
	VISIT DATE: 11/08/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA reviewed multiple resident and staff records. LPA observed resident records to be incomplete and missing information. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

Administrator will submit updated copies of LIC500, LIC610E, and Liability Insurance to the Department within 10 business days.

The following deficiencies were cited per California Code of Regulations and noted on the attached LIC809-D page. LPA provided Administrator technical assistance on staff records, emergency disaster plan, and infection control plan.

An exit interview was conducted with Administrator Lucia Totanes, whose signature below confirms receipt of a copy of this report, two LIC9102TA forms, one LIC9102TV forms, and the Licensee Appeal Rights (LIC9058 01/16).

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 11/08/2023 04:33 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: LUCY'S PLACE	FACILITY NUMBER: 374601035
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 4 of 4 residents medications which poses health and safety risk to 4 of 4 persons in care.
	POC Due Date: 11/22/2023
	Plan of Correction
1 2 3 4	Administrator stated staff will no longer prepour resident medications ahead of time or store in pill boxes. Administrator stated she will arrange an outside trainer to provide medication training to Administrator and staff. Administrator will submit training certificate or sign-in sheet to the Department by POC due date of 11/22/2023.

Type B

Section Cited

CCR

87506(a)

a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 resident files which poses health risk to 4 of 4 persons in care.
	POC Due Date: 11/22/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will review and update 4 of 4 resident records to ensure the resident records are complete and accurate. Administrator will submit LIC9098 form to the Department by POC due date of 11/22/2023.

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 Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6