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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601933
Report Date: 11/21/2024
Date Signed: 11/21/2024 03:56:00 PM

Document Has Been Signed on 11/21/2024 03:56 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:PASEO GUEST HOMEFACILITY NUMBER:
374601933
ADMINISTRATOR/
DIRECTOR:
GIL G. SANTILLA, JRFACILITY TYPE:
740
ADDRESS:13597 PASEO CARDIELTELEPHONE:
(858) 780-2892
CITY:SAN DIEGOSTATE: CAZIP CODE:
92129
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Staff Pat Santilla and Tes CanozaTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Tes Canoza. Staff Pat Santilla arrived during the visit and assisted the LPA. The facility was licensed for a capacity of six (6) non-ambulatory residents, of which five (5) may be bedridden in rooms 4,5,6 and 7. The facility also had an approved hospice waiver for two (2).

Accompanied by staff, the LPA toured the interior and exterior of the facility. The exterior patio was clean, pathways were free of obstructions and trip hazards, and gates were unlocked. Doors, windows, screens, toilets, and showers were in working order. Resident bedrooms contained the required furnishings, and the facility had sufficient space and equipment to facilitate dining, laundry, visitation, and meetings. No pools, nor bodies of water were observed on the premises. A fireplace in the living room area was witnessed to not a have a screen.

Per staff, no firearms, nor ammunition were kept at the facility. A carbon monoxide detector, facility telephone, and fire extinguisher were present and operational. Required licensing postings were observed in visible areas of
the facility.

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 toxic chemicals/poisons accessible to residents.
Medications were labeled, and stored in a locked area.

The LPA interviewed resident and staff and reviewed multiple staff and resident records. The LPA provided Technical Advise and deficiencies observed were cited in an LIC 809D form. Plans of correction were jointly formulated with Staff Pat Santilla. An exit interview was conducted with Pat Santilla, to whom a copy of this report, LIC 809D forms, LIC 811, and the Licensee/Appeal Rights (LIC9058), were provided.
Lizzette TellezTELEPHONE: (619) -76-2351
Sabel MartinezTELEPHONE: (619) 767-2301
DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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 11/21/2024 03:56 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: PASEO GUEST HOME

FACILITY NUMBER: 374601933

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/21/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of records, the licensee did not comply with the section cited above in 2 out 4 staff and did not obtain TB test (S1 and S3) which posed a potential health, safety or personal rights risk to 6 persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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Staff agreed to obatin health screenings for S1 and S3, and submit them to the LPA, by 12/12/2024.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette TellezTELEPHONE: (619) -76-2351
Sabel MartinezTELEPHONE: (619) 767-2301

DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/21/2024 03:56 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: PASEO GUEST HOME

FACILITY NUMBER: 374601933

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/21/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and review of records, the licensee did not comply with the section cited above and did not ensure staff were trained in the above topics, nor that staff received annual training, which posed a potential health, safety or personal rights risk to 6 persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Staff agreed to provide 20 hours of annual training to S3, S4, and S5. Topics will include dementia care, postural supports, restricted health conditions, hospice care, and care and supervision. Staff agrees to submit documents confiming the trainings to the LPA, by 12/20/2024.
Section Cited
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of records, the licensee did not comply with the section cited and did not ensure quarterly emergency drills were conducted, which posed a potential health, safety or personal rights risk to 6 persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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Staff agreed to conduct an emergecny drill and submit documentation confirming the drill was conducted to the LPA, by 12/12/2024
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette TellezTELEPHONE: (619) -76-2351
Sabel MartinezTELEPHONE: (619) 767-2301

DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/21/2024 03:56 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: PASEO GUEST HOME

FACILITY NUMBER: 374601933

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/21/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87307 Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
(7) Fireplaces and open-faced heaters shall be adequately screened.


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 and did not ensure a fireplace was screened, which posed a potential health, safety or personal rights risk to 6 persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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Staff agreed to screen the fireplace and submit proof to the LPA, by 12/12/2024
Section Cited

87705 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 review of records, the licensee did not comply with the section cited above in 1 of 6 residents (R1), which posed a potential health, safety or personal rights risk to 1 person in care.
POC Due Date: 12/20/2024
Plan of Correction
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Staff agreed to obtian a medical assessment for R1 and submit it to the LPA, by 12/20/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette TellezTELEPHONE: (619) -76-2351
Sabel MartinezTELEPHONE: (619) 767-2301

DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024

LIC809 (FAS) - (06/04)
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