374601459-4-10-2023-08-AS-ARAZ-CQRVYF-20230410165103

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601459
Report Date: 04/10/2023
Date Signed: 04/10/2023 04:51:12 PM

Document Has Been Signed on 04/10/2023 04:51 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	DIONISIA HOME CARE I		FACILITY NUMBER:	374601459
ADMINISTRATOR:	VIDA DACANAY		FACILITY TYPE:	735
ADDRESS:	414 SHELL AVENUE		TELEPHONE:	(619) 292-3008
CITY:	NATIONAL CITY	STATE: CA	ZIP CODE:	91950
CAPACITY: 4		CENSUS: 4	DATE:	04/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	House Manager Edgar Dacanay		TIME COMPLETED:	05:00 PM

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 Analyst (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit house manager Edgar Dacanay.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, of which three (3) may be non-ambulator. During today’s inspection, there were a total of four (4) clients in care, of which three (3) were non-ambulatory. This facility does not feature a secured perimeter or delayed egress doors. Required licensing postings were observed in visible areas of the facility.

LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens, hygiene supplies, and Personal Protective Equipment (PPE) were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was comfortable and complaint, at 72 F.

LPAs observed via measurement with a thermometer device that hot water temperature at taps accessible to clients were initially non-compliant: Kitchen was 135 F, Bathroom #1 was 134 F, and Bathroom #2 was 136 F. (During today's visit, staff were able to make adjustments to the facility's water heater, bringing these taps back into compliance.)

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

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

Document Has Been Signed on 04/10/2023 04:51 PM - It Cannot Be Edited

Created By: Alyssa Ramirez On 04/10/2023 at 04:31 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: DIONISIA HOME CARE I	FACILITY NUMBER: 374601459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and measurement, the licensee nitially did not comply with the section cited above for 4 of 4 clients [Clients #1 through #4], which posed an immediate safety risk to persons in care.
	POC Due Date: 04/11/2023
	Plan of Correction
1 2 3 4	Staff made adjustments to the facility's water heater. LPA re-measured the hot water temperatures prior to departure. After adjustment, the kitchen tap reached 119 F, Bathroom #1 reached 118 F, and Bathroom #2 reached 117 F. Hot water accessible to clients was thus made compliant during the visit, resolving the deficiency.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Simon Jacob

LICENSING EVALUATOR NAME:

Alyssa Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: DIONISIA HOME CARE I	FACILITY NUMBER: 374601459
	VISIT DATE: 04/10/2023

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]

There was no pool or large bodies of water on the premises. According to the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed multiple staff and clients, and LPA reviewed multiple staff and client records/files. The interviews did not raise any licensing concerns. The client and staff files contained the required documents. Confidential records were stored in locked areas.

Deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plans of Correction were jointly developed with the licensee. An exit interview was conducted with Dacanay, to whom a copy of this report, the LIC 809-D and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3