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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601076
Report Date: 03/10/2023
Date Signed: 03/10/2023 01:04:04 PM

Document Has Been Signed on 03/10/2023 01:04 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:UNITED CEREBRAL PALSY ASSOC. OF SAN DIEGO COUNTYFACILITY NUMBER:
374601076
ADMINISTRATOR:GILLIAN HENNESSEYFACILITY TYPE:
775
ADDRESS:205 W. MISSION AVENUE, SPACE GTELEPHONE:
(760) 743-1050
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 60CENSUS: 60DATE:
03/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Gillian HennesseyTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 3/10/2023 at 09:15 a.m. LPA was granted entry and met with Administrator Gillian Hennessey, who was informed of the purpose of the visit.

The facility is a one story facility with (3) activity room and (4) bathrooms and changing rooms for clients between the ages of 18-59. LPA conducted a tour of the interior and exterior of the facility and observed the following:

Infection Control: The LPA observed the hand washing stations in the facility had a hand washing signs. LPA also observed gloves in client restrooms, and waste bins with tight fitted lids. The facility also possesses cleaning supplies to do regular cleaning of the facility. The facility is currently screening and taking temperature for facility visitors. The LPA also observed the COVID binder with infection control training, cleaning plan, and up to date guidance on COVID-19.



Physical Plant: LPA observed materials in activity rooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. There is an adequate number of activity rooms for the capacity of the facility. The facility has no outdoor area. Chemicals were observed in a locked closet next to facility rest area and kitchen.

Operating Requirements: The facility has secured a fire clearance that is for 30 ambulatory and 30 non-ambulatory clients. The facility is currently operating at full capacity.

Food Service: LPA observed kitchen and rest area which was observed to be clean and possess equipment in good working condition. LPA observed refrigerators where the clients lunches are being kept.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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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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: UNITED CEREBRAL PALSY ASSOC. OF SAN DIEGO COUNTY
FACILITY NUMBER: 374601076
VISIT DATE: 03/10/2023
NARRATIVE
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Care & Supervision/Administration: Adequate staff are present for the supervision of residents. Emergency exiting plans, telephone numbers and personal rights were found posted in the facility.

Record Review and Resident/Staff Files: LPA noted on the facility staff roster that one (1) staff, Staff #1 S1, was not fingerprinted with CCLD (Community Care Licensing). The facility will receive a type A deficiency for this with attached civil penalty of $500. Plan of Correction was documented for this. All other staff have criminal clearance and updated training along with CPR/First Aid Certification. LPA reviewed the administrator's file and found that there is currently less than the required 30 hours of continuing education on file for the last 24 month period. This will be documented with type B deficiency and plan of correction. All other staff files reviewed were found to be complete. The resident files were also found to be complete.

Health Related Services/ Incidental Medical Services: All resident medication was locked in a staff office.

Disaster preparedness: LPA reviewed the facility emergency and disaster plan. LPA reviewed documentation showing the facility fire alarms had been inspected 10/28/2022. LPA observed all facility exits were clear from obstructions and evacuation routes were posted in every room.

An exit interview was conducted where a copy of this report along with LIC 809-D pages and appeal right were provided to Administrator Gillian Hennessey.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/10/2023 01:04 PM - It Cannot Be Edited


Created By: Janira Arreola On 03/10/2023 at 12:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: UNITED CEREBRAL PALSY ASSOC. OF SAN DIEGO COUNTY
FACILITY NUMBER: 374601076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)(3)
Criminal Record Clearance
(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following: (3) Request the licensee or applicant for a license to request a transfer of a criminal record clearance as specified in Section 82019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above with (1) staff member S1 who was not fingerprinted with the department. The staff member was not currently on the premisis. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2023
Plan of Correction
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The adminsitrator agreed to have the staff fingerprinted and associated to the facility before returning to the facility. The adminsitrator will send the live san form to the LPA by the POC due date. After the staff is cleared, the adminsitrator will associate the staff to the facility.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/10/2023 01:04 PM - It Cannot Be Edited


Created By: Janira Arreola On 03/10/2023 at 12:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: UNITED CEREBRAL PALSY ASSOC. OF SAN DIEGO COUNTY
FACILITY NUMBER: 374601076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82064(d)
Administrator -Qualifications and Duties
(d) The administrator shall receive and document a minimum of 30 clock hours of continuing education every 24 months of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above with the adminsitrator not having the required amount of hours on file for conitnuing education. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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Administrator agreed to send LPA a signed statement quoting the regulation section cited here, stating they have read and understood the regulation and plan on keeping a current record moving forward.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


LIC809 (FAS) - (06/04)
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