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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601190
Report Date: 07/21/2022
Date Signed: 07/21/2022 03:14:49 PM

Document Has Been Signed on 07/21/2022 03:14 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: 17DATE:
07/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Aimee Cabiling, Licensee/AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tricia Danielson and Licensing Program Manager (LPM) Deborah Mullen arrived unannounced to the facility to conduct a case management visit. LPA and LPM entered the facility but were unable to locate any staff. LPA phoned Licensee/Administrator (LIC) Aimee Cabiling to notify her of the presence of Community Care Licensing (CCL) staff in the facility. LIC stated she was driving and was enroute to the facility but would arrive momentarily and did arrive shortly thereafter. LIC reported her husband was in the facility. LPA and LPM were unable to locate anyone other than clients. LIC's son also arrived to assist CCL staff.
During today's visit, LPA and LPM toured the facility with LIC and her son. LPA and LPM observed bed bugs crawling on the walls, window sill, and two (2) client beds in room 306. There was evidence of bed bug excrement on a box spring which was leaning up against furniture in the TV area on the 3rd floor. In room 201, bed bug excrement was observed on the only mattress in the room. Bed bugs were also observed on the floor boards in the hallway on the 3rd floor. Five (5) of five (5) client bathrooms were observed to be unclean and absent of toilet paper. Liquid Plumber and Magic Power bathroom cleaner were observed in a bathroom on the 3rd floor as well. Trash cans in the kitchen were absent of lids. Rodent droppings were observed in the food serving area shelves and drawers. Kitchen refrigerators and freezers were observed to be filled with rotting and/or expired food, undated opened food containers, and drippings from rotting food and/or meats. Flies and gnats were observed on the dining room walls, decor, and furniture. Pre-poured medications in both individual use medication cups and weekly/monthly pill planners were observed in the med room and kitchen area. Expired meds and meds of previous clients were observed in the med room. Per LIC Cabiling, she has attempted to properly discard these meds with a pharmacy and local police but neither would accept it.
Therefore, based on the observations made during today’s visit, the following deficiencies were cited per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted and this reported was provided along with appeal rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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 07/21/2022 03:14 PM - It Cannot Be Edited


Created By: Tricia Danielson On 07/21/2022 at 12:51 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: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2022
Section Cited
CCR
80087(g)

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Building and Grounds- (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
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Licensee stated all cleaning solutions and poisons will be secured preventing client access. Proof of correction will be provided to CCL by POC due date.
Corrected prior to LPA's departure.
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The Licensee did not ensure harmful poisons and cleaning solutions were stored inaccessible to clients. Based on LPA observation, the 3rd floor bathroom contained Liquid Plumber on the sink top and Magic Power bathroom cleaner on the toilet. This poses an immediate health, safety and personal rights risk to clients in care.
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Type A
07/22/2022
Section Cited
CCR80075(k)(5)

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Health Related Services - (k) The following requirements shall apply to medications which are centrally stored: (5) Each client's medication shall be stored in its originally received container. This requirement was not met as evidenced by: The Licensee did not ensure all client medications were stored
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Licensee stated all meds will stay in their original containers or packaging until med administration. Licensee will provide a written statement of understanding of the regulation cited by POC due date.
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in their original containers/packaging, Based on LPA observation, loose pills were observed in medication cups labled with client names and weekly/monthly pill planners. This poses an immediate health, safety, and personal rights risk to clients in care.
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Tricia Danielson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/21/2022 03:14 PM - It Cannot Be Edited


Created By: Tricia Danielson On 07/21/2022 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: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2022
Section Cited
CCR
80075(l)

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Health Related Services- (l) Prescription medications which are not taken with the client upon termination of services, or which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client. This requirement was not met as evidenced by: The Licensee did not ensure
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Licensee stated she will find a proper medication site and dispose of the medications in question. Licensee stated she will do so by July 22, 2022.
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meds of previous client's or expired meds were properly disposed of. Based on LPA observation, expired meds and meds of previous clients were stored in the med room. This poses an immediate health, safety, and personal rights risk to clients in care.
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Type A
07/22/2022
Section Cited
CCR80076(a)(1)

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Food Services- (a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients...All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by: The Licensee
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Licensee stated she will clear all expired, rotting, undated opened food containers and clean all shelving of droppings. Proof of correction to be provided by POC due date.
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did not ensure facility food was stored in a safe and healthful manner. Based on LPA observation, facility refrigerators and freezers contained expired, rotting food, undated open containers, and shelving covered in drippings from meats/rotting food. This poses an immediate health, safey, and personal rights risk to clients in care.
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Tricia Danielson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/21/2022 03:14 PM - It Cannot Be Edited


Created By: Tricia Danielson On 07/21/2022 at 01:21 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: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2022
Section Cited
CCR
80087(a)(1)

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Building and Grounds- (a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety...of clients. (1)The licensee shall take measures to keep the facility free of flies and...insects. This requirement was not met as evidenced by: The Licensee did not take measures to keep
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Licensee stated she will dispose of all mattresses/box springs with evidence of bed bugs. Licensee will contact Terminix to assist assist her in the removal of insects in the dining room and bed bugs in the facility. Proof of correction will be submitted by POC due date.
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the facility free of insects. Based on LPA observation, bed bugs and evidence of bed gugs were found in Room 306, 201, 3rd floor TV area and 3rd floor hallway. Flies and gnats were observed in the dining room as well. This poses a potential health, safety and personal rights risk to clients in care.
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Type B
08/01/2022
Section Cited
CCR80087(a)

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Buidlings and Grounds- (a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety...of clients, employees and visitors. This requirement was not met as evidenced by: The Licensee did not ensure the facility was kept clean and sanitary. Based on LPA observation, 5 of 5 bathrooms
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Licensee stated all client bathrooms will be cleaned and a schedule of cleaning will be maintained. Licensee stated that she has hired help who will starting next month who will help clean bathrooms. Proof of correction will be provided by POC due date.
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located on the 2nd and 3rd floors were found to be unclean and absent of toilet paper. This poses a potential health, safety, and personal rights risk to clients in care.
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Tricia Danielson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/21/2022 03:14 PM - It Cannot Be Edited


Created By: Tricia Danielson On 07/21/2022 at 01:35 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: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2022
Section Cited
CCR
80088(f)(1)

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Furniture, Fixtures, Equipment, and Supplies-(f) Solid waste shall be stored...disposed of in a manner that will not transmit...odors, create...a breeding place...for insects or rodents.(1)All containers...used for...solid wastes shall have tight-fitting covers... shall be in good repair... be leakproof and rodent-proof. This requirement was not met as
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Licensee stated she will obtained trash cans with lids and will removed all evidence of rodent droppings. Proof of corrections to be submitted by POC due date.
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evidenced by: The Licensee did not ensure solid waste was properly stored. Based on LPA observation, all kitchen trash cans did not have lids and rodent droppings were observed in kitchen drawers and shelves. This poses a potential health, safety and personal rights risk to clients in care.
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Tricia Danielson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
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