374601276-2-7-2023-08-AS-SJAB-CNVPWM-20230209104058

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374601276
Report Date: 02/07/2023
Date Signed: 02/07/2023 01:53:52 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/16/2022 and conducted by Evaluator Elizabeth Hamilton

COMPLAINT CONTROL NUMBER: 08-AS-20221116104431

FACILITY NAME:	ANGEL'S GUEST HOME #1		FACILITY NUMBER:	374601276
ADMINISTRATOR:	JENKINS, PATRICIA		FACILITY TYPE:	740
ADDRESS:	9208 BELLAGIO RD		TELEPHONE:	(619) 258-2013
CITY:	SANTEE	STATE: CA	ZIP CODE:	92071
CAPACITY:	6	CENSUS: 5	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	12:28 PM
MET WITH:	Licensee, Cathy McEvoy		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Staff did not ensure facility was free from pests.
Licensee did not keep pathways free from obstruction.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Elizabeth Hamilton and Debbie Correia conducted an unannounced complaint investigation at the facility regarding the above allegations. LPAs were greeted at the front entrance by Caregiver, Lissette Mercado, identified themselves, and were granted entry into the facility. LPA Hamilton and Correia explained the purpose of the visit and the elements of the complaint with Licensee Cathy McEvoy.

The Department’s investigation consisted of resident records reviewed, interviews with staff, residents and outside sources and a tour of the facility.

On November 16, 2022, it was alleged that staff did not ensure facility was free from pests. More specifically, it was alleged the facility had cockroaches during an unspecified timeframe. Interviews with outside sources confirmed the facility had a contract with a Pest Control Company as of June 24, 2021, to treat the facility for pests including cockroaches.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth Hamilton	TELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20221116104431

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANGEL'S GUEST HOME #1	FACILITY NUMBER: 374601276
	VISIT DATE: 02/07/2023

NARRATIVE

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Interviews with staff and outside sources and outside records reviewed confirmed the facility had multiple interior and exterior pest control follow-up treatments during October and November of 2022. An interview with Licensee revealed the facility has had an on-going issue with pests for the last few years. On February 7, 2023, LPAs observed live cockroaches in the food pantry and on the side of the refrigerator. LPAs also observed sticky traps with multiple cockroaches and multiple cockroach remains in kitchen drawers. LPA secured photographs of areas observed.

On November 16, 2022, it was further alleged that the licensee did not keep pathways free from obstruction. On November 21, 2022, LPA Hamilton observed the outdoor passageways leading out to both side gate exits to be blocked with various items, including furniture. LPA further observed the garage filled with storage items with no pathway to exit. LPA secured photographs of areas observed.

The Department has investigated the allegations of staff did not keep facility free from pests and Licensee did not keep pathways free from obstruction. Based on evidence obtained, the allegations are substantiated which means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies are cited in accordance with the California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D.

An exit interview was conducted with Licensee and a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058 01/16) was provided. Licensee signature below confirms receipt of the documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth Hamilton	TELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20221116104431

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANGEL'S GUEST HOME #1	FACILITY NUMBER: 374601276
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/09/2023 Section Cited CCR 87555	1 2 3 4 5 6 7	87555 General Food Service Requirements (b)The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated they would aquire new pest control services, wipe down the kitchen pantry, kitchen drawers and side of the refrigerator daily and implement a kitchen cleaning log for the next month. Licensee stated they would submit verification to the department by 03/09/2023.
	8 9 10 11 12 13 14	Based on LPA observations, Licensee had an infestation at the facility. This posed a potential health risk to 6 out of 6 residents in care.	8 9 10 11 12 13 14
Type B 03/09/2023 Section Cited CCR 87307	1 2 3 4 5 6 7	87307 Personal Accommodations and Services (d)(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated they would remove all trash items from both side exits and the garage and will purchase a storage shed to store remaining items. Pictures will be sent to the deparmtent 03/09/2023.
	8 9 10 11 12 13 14	Based on LPA observations, the licensee did not keep pathways free from obstruction. This posed a potential safety risk to 6 out of 6 residents in care.	8 9 10 11 12 13 14

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	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth Hamilton	TELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

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