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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601035
Report Date: 12/07/2023
Date Signed: 12/07/2023 03:41:14 PM


Document Has Been Signed on 12/07/2023 03:41 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:
12/07/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Caregiver Victoria DaoTIME COMPLETED:
03:45 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. On 12/4/2023, LPA Ruiz conducted a second POC visit and confirmed that one of the two deficiencies had been corrected and issued a $700 civil penalty for failure to correct deficiency 87506(a).

During today's visit, LPA observed residents in care, reviewed resident records, and spoke with staff.

On 12/6/2023, Caregiver Dao notified LPA Ruiz that the resident records had been completed. During today's visit, LPA reviewed resident records and confirmed that they were complete and contained the required documents. Therefore, deficiency 87506(a) has been cleared as of 12/6/2023. An additional civil penalty of $100 per day for 2 days totaling $200 is being assessed for failure to correct for the time period of 12/4/2023 through 12/6/2023. No further civil penalties were assessed.

An exit interview was conducted with Caregiver Victoria Dao, whose signature below confirms receipt of a copy of this report, an LIC421, and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
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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