374601933-11-28-2023-08-AS-SMAZ-CXZVBQ-20231128151753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601933
Report Date: 11/28/2023
Date Signed: 11/28/2023 03:17:58 PM

Document Has Been Signed on 11/28/2023 03:17 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 HOME		FACILITY NUMBER:	374601933
ADMINISTRATOR:	GIL G. SANTILLA, JR		FACILITY TYPE:	740
ADDRESS:	13597 PASEO CARDIEL		TELEPHONE:	(858) 780-2892
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92129
CAPACITY:	6	CENSUS: 5	DATE:	11/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Owner Pat Santilla, and Caregiver Teresita Canoza		TIME COMPLETED:	03:30 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) Sabel Martinez conducted an unannounced Required Annual Inspection visit. The LPA identified himself to, and discussed the purpose of the visit with Caregiver Teresita Canoza. Administrator Pat Santilla arrived during the visit, and assisted the LPA. The facility was licensed for a capacity of six (6) resident, non-ambulatory in rooms four (4), five (5), six(6), and seven (7). The facility was also approved for Hospice waiver of two (2). At the time of the visit the facility had five (5) residents.

The LPA, accompanied by Caregiver Canoza, 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, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, visitation, meetings, and client activities.

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 clients. Medications were labeled, and stored in a locked area.

No pools or bodies of water on the premises. Per staff, no firearms or ammunition are kept at the facility. A Fire extinguisher was also observed.

The LPA interviewed staff and reviewed multiple staff and resident records/files. Staff records indicated the 1st aid certificates had expired in 2021. This deficiency was cited in an LIC 809D, and a plan of correction was jointly formulated with the Owner Pat Santilla.

An exit interview was conducted with Santilla, to whom a copy of this report, LIC 809D, and the Licensee/Appeal Rights (LIC9058), were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

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 2

Document Has Been Signed on 11/28/2023 03:17 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: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411d

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and review of records, the licensee did not comply with the section cited above in 7 out of 7 staff employed at the facility, which poses/posed a potential health, safety or personal rights risk to 5 of 5 persons in care.
	POC Due Date: 12/28/2023
	Plan of Correction
1 2 3 4	Owner agreed to provide 1st aid training to all staff and submit proof of completion to the LPA, by 12/28/23.

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) -76-2351
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2