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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601648
Report Date: 11/07/2024
Date Signed: 11/07/2024 04:00:33 PM

Document Has Been Signed on 11/07/2024 04:00 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:LAKE MURRAY HEALTH CARE CENTERFACILITY NUMBER:
374601648
ADMINISTRATOR/
DIRECTOR:
LOURDES G GONZALESFACILITY TYPE:
740
ADDRESS:7867 LAKE ANDRITA AVENUETELEPHONE:
(619) 464-5640
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:48 PM
MET WITH:Caregiver Elisa JonesTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Iby Strong and David Roman conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Elisa Jones. Administrator David Gonzales. According to the facility’s license, the facility has a maximum capacity of six clients, of whom all may be non-ambulatory.

LPAs toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The outdoor trash bins did not have lids.

Cooking/dining equipment and utensils were present. Medications were labeled, as required, but pre-poured.



No pools or bodies of water on the premises. Per David, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible.

Resident records reviewed had required documentation, Resident 1 (R1) who is diagnosed with a major neurocognitive disorder does not have an updated physician report. Additionally, the auditory alarm on doors leading to the outdoors were not in working condition.

Staff records reviewed contained required documentation.

An exit interview was conducted with Administrator David Gonzales, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22), LIC 809-D and LIC 9201 were provided during the visit.

Simon JacobTELEPHONE: (619) -76-2306
Iby StrongTELEPHONE: 619-481-0846
DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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 11/07/2024 04:00 PM - 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: LAKE MURRAY HEALTH CARE CENTER

FACILITY NUMBER: 374601648

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

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 one of six residents in carewhich poses/posed health risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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Licensee agrees to request an updated LIC602 for R1 by POC date.
Section Cited
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in one of six residents which poses safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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Licensee agrees to repair all auditory alarms by POC date for all doors leading to the outdoors.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon JacobTELEPHONE: (619) -76-2306
Iby StrongTELEPHONE: 619-481-0846

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024

LIC809 (FAS) - (06/04)
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