374602011-9-21-2023-08-AS-ARAZ-CVVTZH-20230921151023

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602011
Report Date: 09/21/2023
Date Signed: 09/21/2023 03:25:23 PM

Document Has Been Signed on 09/21/2023 03:25 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	PLUMERIA GARDENS # 1		FACILITY NUMBER:	374602011
ADMINISTRATOR:	ROBERT ARMSTRONG		FACILITY TYPE:	735
ADDRESS:	1156 CAMINO DEL REY		TELEPHONE:	(619) 941-1940
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91910
CAPACITY: 4		CENSUS: 2	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Licensee Robert Armstrong		TIME COMPLETED:	03:30 PM

NARRATIVE

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This is an amendment from today’s visit (9/21/2023). 809 was amended due to licensee Robert Armstrong locating health screening report (LIC503) and TB test for staff (S1) that was missing during inspection.

Deficiency was issued during inspection but amended to list no deficiencies due to licensee locating document while licensing program analyst Alyssa Ramirez was onsite. No deficiencies observed.

An exit interview was conducted with the licensee Robert Armstrong to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PLUMERIA GARDENS # 1	FACILITY NUMBER: 374602011
	VISIT DATE: 09/21/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

LPA interviewed staff/client and reviewed multiple staff and client records/files. One (1) out of four (4) staff (S1) files was missing health screening (LIC 503) and TB test. All files which LPA reviewed contained all other required documents. Confidential records were stored in locked areas.

Deficiencies were cited for missing staff records per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Armstrong, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/21/2023 03:10 PM - It Cannot Be Edited

Created By: Alyssa Ramirez On 09/21/2023 at 03:02 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PLUMERIA GARDENS # 1	FACILITY NUMBER: 374602011
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview & record review, the licensee did not comply with the section cited above in one (1) out of four (4) staff (S1) by not having health screening record (LIC 503) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/21/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that S1 gets a completed health screening form (LIC503) and will email completed form to LPA Ramirez by POC due date.

Type B

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview & record review, the licensee did not comply with the section cited above in one (1) out of four (4) staff (S1) by not havingTB test which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/21/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that S1 gets a TB test and will email results to LPA Ramirez 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:

Simon Jacob

LICENSING EVALUATOR NAME:

Alyssa Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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