374601552-12-20-2023-08-AS-NPED-CYPM6E-20231220081948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601552
Report Date: 12/19/2023
Date Signed: 12/20/2023 08:21:49 AM

Document Has Been Signed on 12/20/2023 08:21 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	LILY OF THE VALLEY II		FACILITY NUMBER:	374601552
ADMINISTRATOR:	ELISOL PUNAY		FACILITY TYPE:	740
ADDRESS:	11419 WESTONHILL DRIVE		TELEPHONE:	(858) 271-6849
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92126
CAPACITY:	6	CENSUS: 6	DATE:	12/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Staff, Rodelio Aquino		TIME COMPLETED:	06:00 PM

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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility by Staff, Editha Daep. The visit was conducted with Staff, Rodelio Aquino.

LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, However, there was not a sufficient supply of Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents measured at 129 F..

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 sharp objects, and toxic chemicals/poisons accessible to residents. The cleaning supplies under the kitchen sink, had a broken lock on the cabinet. Knives were in an unlocked drawer in the kitchen, accessible to all residents. There were medications in the fridge, made accessible to all residents. Gardening tools to include shovels, rake, and sharp digging tools were accessible in the backyard, along with a cleaning supply and paint. A resident uses syringes and the facility does not have a sharps container to properly dispose of the syringes. The backyard had unwanted clutter piled up on the tables. Multiple window screens were torn and ripping.

No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, and facility telephone were all working. The facility did not have sufficient emergency lighting. First aid kit was incomplete, there was no manual or tweezers. Required licensing postings were not all posted. The facility does not have an Emergency Disaster Plan. The facility did not report an incident involving a resident going to the hospital. Continued on an LIC 809C.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LILY OF THE VALLEY II	FACILITY NUMBER: 374601552
	VISIT DATE: 12/19/2023

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There is a bedridden resident in a non-bedridden room. The facility has a hospice waiver for one (1) resident but currently has two (2) residents on hospice. Facility does not have written statement on file for a resident sharing a bedroom with a hospice resident. The inspection was not completed due to time constraints, an Annual Continuation visit will be conducted at a later date.

Deficiencies were observed and cited during today's annual inspection. An exit interview was conducted with Staff, Rodelio Aquino to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/20/2023 08:21 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LILY OF THE VALLEY II	FACILITY NUMBER: 374601552
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews, the licensee did not ensure the bedridden resident was in the approved fire clearance bedridden room in 1 out of 6 [R1] residents which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	Staff, Rodelio Aquino stated the bedridden resident was relocated to another room due to cost. Staff relocated the bedridden resident to the approved fire clearance room, Room #3, during the visit.

Type A

Section Cited

CCR

87465(h)(2)

The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews, the licensee did not ensure resident medications stored in the fridge were locked/inaccessible for 6 out of 6 residents [R1-R6] which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	Staff, Rodelio Aquino was not aware all medications shall be locked, such as the medications located in the fridge. Staff Aquino stated he will purchase a medication lock box and provide proof by POC due date.

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/20/2023 08:21 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LILY OF THE VALLEY II	FACILITY NUMBER: 374601552
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not ensure cleaning solutions were inaccessible for 6 out of 6 residents [R1-R6] which poses an immediate health and safety risk to persons in care
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	Staff, Rodelio Aquino stated staff forget to lock the cleaning supplies. Staff Aquino agreed to attend vendor training along with staff on Storage Space to ensure cleaning supplies are inaccessible. Aquino will schedule the training by POC due date and submit proof of training within 2 weeks.

Type A

Section Cited

CCR

87705(f)(1)

The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not ensure knives and gardening tools and supplies were inaccessible to 6 out of 6 residents [R1-R6] which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	Staff Aquino stated the staff forget to lock the knives and items that pose a danger. Staff Aquino agreed to attend vendor training along with staff regarding items that can pose a danger are inaccessible to residents. Aquino will schedule the training by POC due date and submit proof of training within 2 weeks.

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/20/2023 08:21 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LILY OF THE VALLEY II	FACILITY NUMBER: 374601552
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not ensure the hot water was within regulation temperature for 6 out 6 residents [R1-R6] which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	Staff Rodelio Aquino placed a warning sign above the sink. Staff Aquino stated they will ensure the water is in compliance by POC due date.

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/20/2023 08:21 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LILY OF THE VALLEY II	FACILITY NUMBER: 374601552
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not ensure the facility has current liability insurance in 6 out of 6 residents [R1-R6] which posed a potential health and safety risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Staff Rodelio Aquino stated he will speak with the Administrator and obtain a copy of current Liability Insurance by POC due date.

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not ensure the facility was clean and safe due to all the unwanted items in the backyard and multiple torn window screens for 6 out of 6 residents [R1-R6] which posed a potential health and safety risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Staff Rodelio Aquino stated they will remove all the unwanted items in the backyard and repair or replace all the torn window screens by POC due date.

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

Page: 6 of 8

Document Has Been Signed on 12/20/2023 08:21 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LILY OF THE VALLEY II	FACILITY NUMBER: 374601552
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87632(a)

In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. The request shall include, but not be limited to the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews, the licensee did not ensure all hospice residents were covered under the hospice waiver in 1 out of 6 residents [R2] which posed a potential health and safety risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Staff Rodelio Aquino thought the facility's Hospice Waiver was for two residents. Staff Aquino stated the facility will submit a hospice exception for R2 or a hospice increase by POC due date.

Type B

Section Cited

CCR

87303(

Solid waste shall be stored and disposed of as follows: Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews, the licensee did not ensure the resident using syringes has a proper container to dispose of syringes in 1 out of 6 residents [R3] which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Staff Rodelio Aquino stated they will purchase the resident a Sharps Container and provide proof by POC due date.

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

Page: 7 of 8

Document Has Been Signed on 12/20/2023 08:21 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LILY OF THE VALLEY II	FACILITY NUMBER: 374601552
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(8)

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not ensure the first aid was complete in 6 out of 6 residents {R1-R6] which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Staff Rodelio Aquino stated he will purchase a current First Aid Manual and Tweezers for the kit by POC due date.

Type B

Section Cited

CCR

87211(a((1)

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not report an incident that occurred weeks ago 1 out of 6 residents [R3] which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Staff Rodelio Aquino forgot to submit an incident report for R3's hospitalization 2 weeks ago. Staff Aquino stated he will submit an incident report and attend training on Reporting Requirements and submit proof of training by POC due date.

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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