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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602224
Report Date: 12/26/2023
Date Signed: 12/26/2023 04:23:28 PM

Document Has Been Signed on 12/26/2023 04:23 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MORNING BREEZE HOME IVFACILITY NUMBER:
374602224
ADMINISTRATOR:EMERITA A. GARCIAFACILITY TYPE:
735
ADDRESS:423 HORIZON VIEW DRTELEPHONE:
(619) 426-6369
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: 6CENSUS: 4DATE:
12/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:DSP Josephine RocamoraTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with DSP Josephine Rocamora. LPA also spoke via phone with Licensee Emerita Garcia during the visit.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/22/2023), involving Client #1 (C1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a facility tour and welfare check on clients in care, finding no immediate safety concerns. LPA also reviewed pertinent care records and interviewed the clients present and relevant staff.

No deficiencies were cited for the incident itself. However, during records review, LPA observed: a) Licensee did not possess a written Functional Capabilities Assessment for C1, as was required; b) Licensee did not possess a written Needs and Services Plan for C1 (or other equivalent care plan), as was required; and c) Licensee did not maintain a written Absentee Notification Plan as part of C1’s record of care, as was required. Licensee interview confirmed these points to be true.

Two (2) deficiencies were cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D pages). Plans of Correction was jointly developed with the licensee.

An exit interview was conducted with Rocamora. A copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Rocamora and Garcia during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2023
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 3
Document Has Been Signed on 12/26/2023 04:23 PM - It Cannot Be Edited


Created By: Dang Nguyen On 12/26/2023 at 04:08 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: MORNING BREEZE HOME IV
FACILITY NUMBER: 374602224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/25/2024
Section Cited
CCR
80069.2(a)

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80069.2 Functional Capabilities Assessment: “(a) In order to determine whether the facility’s program meets a client’s services needs, the licensee of an ARF shall assess the client’s need for personal assistance and care by determining his/her functional capabilities. The assessment shall be in writing [and] shall be used in developing the Needs and Service Plan…”
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Licensee agreed to complete an LIC9172 Functional Capability Assessment for C1, to file it in C1’s care binder. Licensee agreed to E-mail a copy of C1's LIC9172 to LPA, by the POC due date. Licensee agreed to audit other clients’ files to ensure each has a completed LIC9172.
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This requirement was not met, as evidenced by: Based on records review and staff interview, for 1 of 4 clients (C1), licensee did not perform a written assessment of his/her need for personal assistance and care by determining his/her functional capabilities, which posed a potential health and personal rights risk to persons in care.
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Type B
01/25/2024
Section Cited
CCR80068.2(a)

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80068.2 Needs and Services Plan: “(a) The licensee shall complete a Needs and Services Plan for each client…” This requirement was not met, as evidenced by:
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Licensee agreed to contact San Diego Regional Center (SDRC) to obtain a copy of C1’s latest Client Intake Referral and C1’s latest Individual Program Plan (IPP), and to place both in C1’s care binder. Licensee also agreed to author an LIC625 Appraisal/Needs and Services Plan for C1. Licensee agreed to E-mail a copy of the above three documents to LPA, by the POC due date. Licensee agreed to audit other clients’ files to ensure each has an LIC625, an SDRC IPP, and an SDRC Client Intake Referral.
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Based on LPA observation and staff interview, for 1 of 4 clients (C1), licensee did not complete a Needs and Services Plan, which posed a potential health and personal rights risk to persons in care.
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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
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/26/2023 04:23 PM - It Cannot Be Edited


Created By: Dang Nguyen On 12/26/2023 at 04:13 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: MORNING BREEZE HOME IV
FACILITY NUMBER: 374602224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/25/2024
Section Cited
HSC
1507.15

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1507.15 Absentee notification plan for missing residents or participants: “Every community care facility that provides adult residential care… shall…develop and comply with an absentee notification plan for each resident... The plan shall be part of the written Needs and Services Plan [and] shall include…a requirement that an administrator of the facility, or his or her designee, inform the resident’s…authorized representative when that resident…is missing from the facility and the circumstances…in which [they]…shall notify local law enforcement…”
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Licensee agreed to write an individualized Absentee Notification Plan for C1 (and which also meets the requirements of CA H&S Code 1507.15), to place a copy if it inside C1’s care binder next to C1’s Needs and Services Plan, and to train its direct care staff on the Plan. Licensee agreed to E-mail the Plan and the training sign-in sheet to LPA, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, the licensee did maintain an Absentee Notification Plan as part of the written Needs and Services Plan (or elsewhere in the record of care) for 1 of 4 clients (C1), which posed a potential safety risk to persons in care.
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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
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2023


LIC809 (FAS) - (06/04)
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