374601317-9-19-2023-08-AS-RGAZ-CVTQ82-20230919115603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601317
Report Date: 09/19/2023
Date Signed: 09/19/2023 11:56:08 AM

Document Has Been Signed on 09/19/2023 11:56 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:	CHATEAU ST. MARK HOMES 5 / PLAYA DEL REY HOUSE		FACILITY NUMBER:	374601317
ADMINISTRATOR:	MARTIN LOPEZ		FACILITY TYPE:	735
ADDRESS:	105 PLAYA DEL REY		TELEPHONE:	(760) 696-3777
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92054
CAPACITY: 4		CENSUS: 1	DATE:	09/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Staff Yolanda Dizon		TIME COMPLETED:	11:55 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analysts (LPAs) Riza Alvarez and Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were greeted and allowed entry into the facility by facility staff Yolanda Dizon, to whom LPA discussed the purpose of the visit.

According to the facility’s license, the facility has a maximum capacity of four (4) developmentally disabled adults, all of whom may be non-ambulatory. During today’s inspection, there was one (1) client in care.

LPA, accompanied by Staff Dizon, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and generally in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant. Hot water temperature at taps accessible to clients were also compliant.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: CHATEAU ST. MARK HOMES 5 / PLAYA DEL REY HOUSE	FACILITY NUMBER: 374601317
	VISIT DATE: 09/19/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per Staff Dizon, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff present. LPA interviews did not raise any licensing concerns. LPAs reviewed multiple staff and client records/files. Client files contained required documents. Staff files were missing one required document. Confidential records were stored in locked areas.

Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC809-D page). A Plan of Correction was jointly developed with Staff Dizon.

An exit interview was conducted with Staff Yolanda Dizon, to whom copies of this report, the LIC809-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 09/19/2023 11:56 AM - It Cannot Be Edited

Created By: Riza Gloria Alvarez On 09/19/2023 at 11:42 AM

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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CHATEAU ST. MARK HOMES 5 / PLAYA DEL REY HOUSE	FACILITY NUMBER: 374601317
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on inspection of the physical plant, the licensee did not comply with the section cited above in one (1) out of six (6) window screens which poses a potential health risk to persons in care. Licensee did not comply with the section cited above in one (1) out of one (1) toilet seat in the client's bathroom, with poses a potential safety risk to persons in care.
	POC Due Date: 10/19/2023
	Plan of Correction
1 2 3 4	Licensee will submit to CCLD proof of repaired/replaced window screen and replaced toilet seat, such as photos and proof of purchase of materials.

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one (1) out of five (5) staff which poses a potential health risk to persons in care.
	POC Due Date: 10/19/2023
	Plan of Correction
1 2 3 4	Licensee will submit to CCLD copy of completed LIC503 for one (1) staff.

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

LICENSING EVALUATOR NAME:

Riza Gloria Alvarez

LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3