374602023-6-21-2024-08-AS-CLOZ-D6FP2Q-20240621105620

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602023
Report Date: 06/21/2024
Date Signed: 06/21/2024 10:57:28 AM

Document Has Been Signed on 06/21/2024 10:57 AM - 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:	PASCUA RCFE		FACILITY NUMBER:	374602023
ADMINISTRATOR:	JESUSA PASCUA		FACILITY TYPE:	740
ADDRESS:	1268 STAMEN ST		TELEPHONE:	(619) 266-0209
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92114
CAPACITY:	4	CENSUS: 4	DATE:	06/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Administrator's Jesusa Pascua and Renaldo Pascua		TIME COMPLETED:	11:05 AM

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) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by caregiver Erlinda Palmaria. LPA discussed the purpose of the visit with caregiver Palmaria. Licensee Jesusa Pascua and Administrator Reynaldo Pascua later arrived and joined the visit. According to the facility’s license, there may be a maximum of four (4) residents two (2) of whom may be non-ambulatory in at any given time at the facility site. During today’s inspection, the facility’s current census is 4 residents living at the facility. There were no clients present at the facility site during the inspection. LPA, accompanied by caregiver Palmaria and later with Licensee Pascua, 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, laundry, visitation, meetings, and activities. The facility’s ambient internal temperature was comfortable and compliant, at 76 degrees Fahrenheit (F). Hot water temperature at taps accessible to resident were also compliant: kitchen sink measured hot water at 115.9 degrees F; sink in restroom #1 delivered hot water at 120 degrees F; and sink in restroom #2 delivered hot water at 120 degrees F. Licensee assured LPA that hot water will be monitored not to exceed the current temperature. There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present, and all safely cleaned and stored. There were no toxic chemicals/poisons accessible to residents. Medications were properly labeled, as required, and stored in locked cabinet. The facility-maintained medication logs which LPA reviewed. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

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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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: PASCUA RCFE	FACILITY NUMBER: 374602023
	VISIT DATE: 06/21/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per licensee Pascua, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was present (01) and serviced within the last 12 months. First aid kit(s) were complete and readily accessible.

LPA was not able to interview residents as they were at their program but was able to interview staff. LPA reviewed staff and resident records. During today’s visit there were no residents on the facility premise. LPA interview did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked cabinet. Required licensing postings were observed in a visible area of the facility.

There were no deficiencies observed or cited during today's annual inspection.

An exit interview was conducted with Licensee Pascua to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Licensee Pascua to submit their current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, Emergency Disaster Plan LIC 610-E, Residential Infection Control Plan LIC 9282 (6/23), and a copy of their updated Liability Insurance to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

LIC809 (FAS) - (06/04)

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