<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602117
Report Date: 06/29/2022
Date Signed: 06/29/2022 02:28:37 PM


Document Has Been Signed on 06/29/2022 02:28 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:TOMAS RESIDENTIAL CAREFACILITY NUMBER:
374602117
ADMINISTRATOR:NORMA TOMASFACILITY TYPE:
740
ADDRESS:6344 JOUGLARD STTELEPHONE:
(619) 434-5235
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:6CENSUS: 3DATE:
06/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Norma Tomas, AdministratorTIME COMPLETED:
01:35 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) Daniel Pena conducted an unannounced Case Management visit. LPA was met by Norma Tomas, Administrator and was granted entry into the facility. LPA met with Ms. Tomas and later with Licensee Abraham Tomas to discuss the purpose of the visit.

This visit was initiated due to a reported incident involving Resident #1 (R1), which was received by CCL on July 27, 2020. Ms. Tomas was provided with (LIC811) Confidential Names Form in order to identify R1. On June 11, 2020, R1 eloped from the facility and was later transported to a medical center and admitted for care. Hospital personnel contacted the facility to discuss R1’s discharge and return to the facility.

According to facility staff interviews, R1 was refused readmittance to the facility for being under the influence of methamphetamine. Staff interviews also revealed staff refused R1’s return from the hospital as the facility believed R1 required placement into a locked facility. Interviews and records reviewed revealed that the Licensee did not conduct a reappraisal of R1.

During today's visit, LPA reviewed records and interviewed staff. A citation was issued.

This deficiency is noted on the attached 809-D and is cited in accordance with the California Code of Regulations, Title 22. This report was discussed with Licensee Tomas. A copy of this report, along with Licensee/Appeal Rights, was provided to the Licensee at the conclusion of the visit.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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 06/29/2022 02:28 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: TOMAS RESIDENTIAL CARE
FACILITY NUMBER: 374602117

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2022
Section Cited

1
2
3
4
5
6
7
87463(c) Reappraisals: The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on records reviewed and interviews conducted, the licensee did not conduct a reappraisal to document changes in R1’s condition prior to eviction, which posed an immediate health risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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 JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2