374602117-2-12-2024-08-AS-CLOZ-D2DTF9-20240212134110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602117
Report Date: 02/12/2024
Date Signed: 02/12/2024 01:44:24 PM

Document Has Been Signed on 02/12/2024 01:44 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:	TOMAS RESIDENTIAL CARE		FACILITY NUMBER:	374602117
ADMINISTRATOR:	NORMA TOMAS		FACILITY TYPE:	740
ADDRESS:	6344 JOUGLARD ST		TELEPHONE:	(619) 434-5235
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92114
CAPACITY:	6	CENSUS: 3	DATE:	02/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:			TIME COMPLETED:	02:00 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) 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 Licensee Abraham Tomas. LPA discussed the purpose of the visit with Licensee Tomas and Administrator Norma Tomas. According to the facility’s license, there may be a maximum of six (6) residents all of whom may be non-ambulatory in at any given time at the facility site. The facility does have a dementia plan of operation on file. During today’s inspection, the facility’s current census is 3 residents living at the facility. There were 2 residents present at the facility site during the inspection, but one left during the inspection. LPA, accompanied by Licensee and Administrator, toured the interior and exterior parts 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 72 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were also compliant: kitchen sink measured hot water at 119 degrees F; sink in restroom #1 delivered hot water at 107.4 degrees F. 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 stored. There were no toxic chemicals/poisons accessible to residents. Medications were properly labeled, as required, and stored in a locked cabinet. LPA inspected the medication storage and found that medications were properly labeled and stored. [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: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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: TOMAS RESIDENTIAL CARE	FACILITY NUMBER: 374602117
	VISIT DATE: 02/12/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

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

LPA interviewed residents, and reviewed staff and resident records. During today’s visit there were 3 residents on the facility premise with one who left during the inspection. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

There were no deficiencies cited during today's annual inspection, but a Technical Advisory was provided.

An exit interview was conducted with Administrator Tomas 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 Administrator Norma Tomas to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, Emergency Disaster Plan LIC 610-E, and Residential Infection Control Plan LIC 9282 (6/23), 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: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC809 (FAS) - (06/04)

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