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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601190
Report Date: 05/31/2022
Date Signed: 05/31/2022 01:35:57 PM

Document Has Been Signed on 05/31/2022 01:35 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:REAL GUEST HOME OF NORTH COUNTYFACILITY NUMBER:
374601190
ADMINISTRATOR:AIMEE CABILINGFACILITY TYPE:
735
ADDRESS:1225 E. PENNSYLVANIA AVENUETELEPHONE:
(760) 291-1349
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 49CENSUS: 18DATE:
05/31/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Aimee Cabiling, AdministratorTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Javina George arrived at the facility unannounced for the purpose of a complaint investigation (#18-AS-20220526150931). LPA was greeted and granted entry by Administrator Aimee Cabiling. During today's inspection, LPA George observed the following deficiencies:

LPA conducted a tour of the interior and exterior of the facility. At 11:00am Upon entry to the right standing at the front door, in the hallway were grocery baskets full of bread, 7-layer bean dip, vegetables, potatoes and fruits that had mold or were rotten, there was an odor of spoiled food. LPA observed for there to be several fruit flies surrounding the items in the basket. Administrator disposed of the fruit during LPAs visit.

At 11:49am Inside of the kitchen LPA observed there were 2 pill calendars that were sitting on an end table, that the Administrator Aimee stated belonged to her. LPA observed multivitamins and other over the counter vitamins such as vitamin C and Zinc sitting on the counter. The residents do not have access to the kitchen as it is locked.

However, the kitchen was observed to be cluttered, with several cups, Moldy bread, croissants and left over food from lunch (pot of soup, sandwiches) etc. A deficiency is being cited.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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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Document Has Been Signed on 05/31/2022 01:35 PM - It Cannot Be Edited


Created By: Javina George On 05/31/2022 at 01:04 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: REAL GUEST HOME OF NORTH COUNTY
FACILITY NUMBER: 374601190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2022
Section Cited
CCR
80076(17)

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80076 Food Service
(17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin. This requirement is not met as evidenced by: the licensee did not keep the kitchen clean on at least 1 out of 1 times.
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The licensee agrees to remove the clutter from the kitchen. Proof is to be submitted by 5pm on the due date indicated.

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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:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022


LIC809 (FAS) - (06/04)
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