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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601276
Report Date: 04/25/2024
Date Signed: 04/26/2024 02:52:15 AM


Document Has Been Signed on 04/26/2024 02:52 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:ANGEL'S GUEST HOME #1FACILITY NUMBER:
374601276
ADMINISTRATOR:JENKINS, PATRICIAFACILITY TYPE:
740
ADDRESS:9208 BELLAGIO RDTELEPHONE:
(619) 258-2013
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY:6CENSUS: 5DATE:
04/25/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee Cathy McEvoyTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Debbie Correia made an unannounced continuation visit of the required annual inspection. LPA was granted entry into the facility by Licensee McEvoy, identified herself, and stated the purpose of today’s visit, to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6.

During the initial annual inspection LPA observed the facility was equipped with fire extinguishers inspected on 4/23/2024, toxins and medications were secured in locked cabinets and inaccessible to residents in care. The facility had current liability insurance per Title 22 mandate. The facility was sanitary, in good repair, and free from pests.

A facility records review revealed staff and resident records were incomplete. The facility was operating under an inactive Limited Liability Corporation (LLC) business License, did not have a certified or designated Administrator, employed uncleared staff, staff were not CPR or First Aid certified, and the facility did not maintain documentation of staff training or required quarterly disaster drills. The administration of medication was not properly documented, and the required postings were not displayed.

Based on the facility inspection, deficiencies were observed and noted on the attached LIC 809Ds. Civil penalties were also assessed on the attached LIC 421BG.

An exit interview was conducted with Licensee, McEvoy, and a copy of this report along with the Licensee Rights (LIC 9058) along with Civil Penalty Assessment (LIC 421BG) will be provided. McEvoy’s signature below confirms receipt of these documents.

SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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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Document Has Been Signed on 04/26/2024 02:52 AM - It Cannot Be Edited

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: ANGEL'S GUEST HOME #1
FACILITY NUMBER: 374601276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(c)
A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department:
(1) A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02). (2) A copy of the individual's: (A) Driver's license, or (B)Valid identification card issued by the Department of Motor Vehicles, or (C)Valid photo identification issued by another state or the United States government if the individual is not a California resident. (3)Any other documentation required by the Department (e.g., LIC 508, Criminal Record Statement [Rev. 1/03] and job description).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a records review, the licensee did not comply with the section cited above in 1 out of 5 persons [S1] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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The Licensee will submit required documentation for S1 to the Department or utilize Guardian to ensure criminal clearance.

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: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/26/2024 02:52 AM - It Cannot Be Edited

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: ANGEL'S GUEST HOME #1
FACILITY NUMBER: 374601276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
The licensee shall ensure that a separate, complete and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviews, the licensee did not comply with the section cited above in 3 out of 5 {R1, R2, R3] residents in care which posed a potential health risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee will conduct resident file review to ensure all records are complete. Licensee also agreed to contact the LTCO to conduct a training on required resident records and assessments.
Type B
Section Cited
CCR
87465(e)
For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.(1) The specific symptoms which indicate the need for the use of the medication.(2) The exact dosage.(3) The minimum number of hours between doses.(4) The maximum number of doses allowed in each 24-hour period.

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 5 out of 5 persons] [S1, S2, S3, S4, S5] which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2024
Plan of Correction
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Licensee will conduct resident file review to ensure all records are complete. Licensee also agreed to contact the LTCO to conduct a training on required resident records and assessments.
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: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 04/26/2024 02:52 AM - It Cannot Be Edited

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: ANGEL'S GUEST HOME #1
FACILITY NUMBER: 374601276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from different emergency scenarios...Documentation of the drills shall include the date, the type of emergency...,and the names of staff participating.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviews, the licensee did not comply with the section cited above poses/posed a potential safety risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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licensee will coordinate training by Cintas Corporation to conduct a disaster drill training with all staff and provide documentation to the department including attendees, date of training, topics covered, and trainee information to the Department by the POC due date.
Type B
Section Cited
HSC
1569.695(b)
A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during a disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviews, the licensee did not comply with the section cited above which poses/posed a potential , safety risk to 5 out of 5 persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Licensee will conduct personnel file review to ensure all records are complete. Licensee also agreed to contact the LTCO to conduct a training on required resident records and assessments.
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: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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