374601175-7-28-2023-08-AS-RGAZ-CU6NVS-20230728104824

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601175
Report Date: 07/28/2023
Date Signed: 07/28/2023 10:48:31 AM

Document Has Been Signed on 07/28/2023 10:48 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	DSC, INC. - BUENA VALLEY HOUSE		FACILITY NUMBER:	374601175
ADMINISTRATOR:	DIANE SPURGEON		FACILITY TYPE:	735
ADDRESS:	1787 DUPONT DRIVE		TELEPHONE:	(619) 460-7333
CITY:	LEMON GROVE	STATE: CA	ZIP CODE:	91945
CAPACITY: 3		CENSUS: 3	DATE:	07/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator Diane Spurgeon		TIME COMPLETED:	10:50 AM

NARRATIVE

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Licensing Program Analyst (LPA) Riza Alvarez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Direct Support Professional II (DSP II) Iliganoa Jennings, to whom LPA discussed the purpose of the visit. Administrator Diane Spurgeon arrived at the facility shortly.

According to the facility’s license, the facility has a maximum capacity of three (3) ambulatory adult clients. During today’s inspection, one (1) client was in care waiting for day program transport, which arrived around 9:00 a.m.. Two (2) clients were at day programs.

LPA, accompanied by DSP II Jennings, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant at 68 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 117.5 F, bathroom #1 sink was 115.7 F and bathroom #2 sink was 118.2 F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: DSC, INC. - BUENA VALLEY HOUSE	FACILITY NUMBER: 374601175
	VISIT DATE: 07/28/2023

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per DSP II Jennings, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed Administrator Spurgeon. LPA interview did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Client files contained required documents. Files of one (1) staff were missing required documents. Confidential records were stored in locked areas.

Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with Administrator Spurgeon.

An exit interview was conducted with Administrator Spurgeon to whom copies of this repo, LIC809-D page, rt and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/28/2023 10:48 AM - It Cannot Be Edited

Created By: Riza Gloria Alvarez On 07/28/2023 at 10:33 AM

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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: DSC, INC. - BUENA VALLEY HOUSE	FACILITY NUMBER: 374601175
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). 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 one (1) out of five (5) facility staff which poses a potential health risk to persons in care.
	POC Due Date: 08/28/2023
	Plan of Correction
1 2 3 4	Licensee will submit to CCL LIC503 (Health Screening) for Staff 1.

Type B

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). 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 one (1) out of five (5) facility staff which poses a potential health risk to persons in care.
	POC Due Date: 08/28/2023
	Plan of Correction
1 2 3 4	Licensee will submit to CCL TB test document for Staff 1.

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:

Denise Powell

LICENSING EVALUATOR NAME:

Riza Gloria Alvarez

LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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