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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601190
Report Date: 10/30/2024
Date Signed: 10/30/2024 01:46:03 PM

Document Has Been Signed on 10/30/2024 01:46 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:REAL GUEST HOME OF NORTH COUNTYFACILITY NUMBER:
374601190
ADMINISTRATOR/
DIRECTOR:		AIMEE CABILINGFACILITY TYPE:
735
ADDRESS:1225 E. PENNSYLVANIA AVENUETELEPHONE:
(760) 291-1349
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 49CENSUS: 18DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:38 AM
MET WITH:Aimee Cabiling, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 10/30/24 at 10:38am Licensing Program Analyst (LPA) Javina George conducted an unannounced 1 year required visit. LPA met with Administrator/Licensee Aimee Cabiling and explained the purpose of the visit. The facility is licensed to serve forty-nine (49) mentally disabled ambulatory clients; ages 18-59. The facility is a multi level structure consisting of three (3) floors with twenty-eight (28) bedrooms and fourteen (14) bathrooms. At the time of the visit there were (2) staff on the premises. On the second floor there are (15) clients residing and on the third floor there are (3) clients residing on the floor. The following observations were made during today's visit:
The hot water was tested and measured at 107.4-109.6,which is within regulatory limits. All smoke and carbon monoxide detectors on each floor were tested and were found to be operable, The signal systems was observed to be functional. The facility has (12) fire extinguishers that need to be serviced in the month of October 2024. Licensee called to schedule the service appointment during today's visit. There are no pools or bodies of water or known guns on the premises.
LPA observed for there to be dead cockroaches on the first floor of the facility. Per the Administrator the facility has an exterminator come to the facility once a month. An invoice was shown, and the appointment was verified LPAs visit. Therefore no deficiency was cited.

The facility was observed to have a 2 day of perishable, and a 7 day supply of nonperishable food items.

LPA conducted a review of client files that were observed to have medical assessments, and admission's agreements. Staff files reviewed revealed that Staff #1 (S1) had not received their initial training, in addition to not have a valid CPR certification. The administrator Aimee was observed to possess valid administrator certification, but no CPR certification. Deficiency cited. Staff were observed to have criminal record clearance, but there is a discrepancy with Staff #1(S1) and the name and facility number, a technical Violation was issued. During today's visit LPA followed up on the outstanding annual fees as they had not been paid prior to the conducted visit. LPA verified that the fees were paid prior to the conclusion of LPAs visit today.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: REAL GUEST HOME OF NORTH COUNTY
FACILITY NUMBER: 374601190
VISIT DATE: 10/30/2024
NARRATIVE
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LPA provided Guardian information. LPA discussed with Licensee to submit an updated an LIC610D, to reflect current plan to combat current illnesses. Licensee agreed to submit by 5pm on Monday 11/4/24.

Based on today's inspection a citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 6).

An exit interview was conducted and a copy of this report, 809D, appeal rights and LIC811-Confidential names list, was reviewed and provided to Licensee/Administrator Aimee Cabiling.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2024 01:46 PM - It Cannot Be Edited


Created By: Javina George On 10/30/2024 at 01:15 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: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Licensee/Administrator agrees to enroll herself and other facility staff in CPR/First aid training. Proof is to be submitted to the department by 5pm on the due date indicated.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/30/2024 01:46 PM - It Cannot Be Edited


Created By: Javina George On 10/30/2024 at 01:15 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: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 2 persons as they did not complete the required training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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The Licensee agrees to have staff #1 and any other staff complete their intial training. Proof will be submitted to the department by 5pm on the due date indicated.
Type B
Section Cited
CCR
80076(a)(17)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (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:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 2 out of 2 times as there were 2dead cockroaches were observed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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No POC due as the exterminator apppointment was scheduled during LPAs visit, and the (2) cockroaches were disposed of during today's visit.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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