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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601895
Report Date: 08/24/2022
Date Signed: 10/04/2022 12:01:39 PM


Document Has Been Signed on 10/04/2022 12:01 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:JOY & JAY HOME CAREFACILITY NUMBER:
374601895
ADMINISTRATOR:ANA OSBORNEFACILITY TYPE:
740
ADDRESS:12946 AMARANTH STTELEPHONE:
(858) 240-7883
CITY:SAN DIEGOSTATE: CAZIP CODE:
92129
CAPACITY:6CENSUS: 6DATE:
08/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Administrator, Ana Osborne , House Manager, Dearme Doverte, and Caregiver, Kenneth DoverteTIME COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA), Sabel Martinez, conducted a case management visit to cite for a deficiency that was observed during a complaint investigation. The LPA was granted entry into the facility by Caregiver, Kenneth Doverte, after identifying himself and disclosing the purpose of the visit. Administrator, Ana Osborne, House Manager, Dearme Doverte, arrived during the visit

During a complaint investigation, the LPA discovered the facility Administrator, Ana Osborne, who is a mandated reporter, had knowledge of possible abuse requiring reporting to the local ombudsman, the Department, and local law enforcement. Based on interviews, and records reviewed, it was determined the facility did not meet the required reporting requirements. Per California Code of Regulations, Title 22, this deficiency was cited on an LIC 809D. A Plan of Correction was jointly formulated with the facility administrator.

An exit interview was conducted with Administrator, Ana Osborne, to whom a copy of the report and Licensee/Appeal Rights (LIC 9058 01/16) were provided to.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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 10/04/2022 12:01 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: JOY & JAY HOME CARE
FACILITY NUMBER: 374601895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2022
Section Cited

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87211 Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by:
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Based on interviews and records reviewed, the Licensee did not report physical abuse of an elder or dependent adult to the local ombudsman, Lincensing, nor local law enforecement. This posed an immediate health, safety, and personal rights risk to 6 of 6 residents in care.
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Administrator agreed to provide the LPA records of the completed training and staff who completed the training by 9/21/22.

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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 PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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