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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602306
Report Date: 01/03/2025
Date Signed: 01/03/2025 02:55:37 PM

Document Has Been Signed on 01/03/2025 02:55 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:RUBIA'S TERRACE ARFFACILITY NUMBER:
374602306
ADMINISTRATOR/
DIRECTOR:		MERCEDES RUBIAFACILITY TYPE:
735
ADDRESS:2660 GROTON PLACETELEPHONE:
(760) 520-3951
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 6CENSUS: 5DATE:
01/03/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Licensee/ Administartor, Mercedes Z RubiaTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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Licensing Program Analyst, (LPA) Kathleen Banrasavong arrived unannounced to follow up on a Serious Incident Report (LIC 624A) received by Community Care Licensing (CCL), Riverside Adult and Senior Regional Office on 01/02/2025. LPA conducted a case management visit on the health, safety and welfare of the residents in care. LPA identified herself, and met with Caregiver, Betty Naguit and explained the purpose of the visit. Additionally, the LPA spoke to the Licensee/ Administrator, Mercedes Rubia over the phone to explain the purpose of the visit. Rubia shortly came later to conduct and complete the visit. There was two (2) staff member on duty at the time of the visit. There were zero (0) clients present at the time of the LPA’s visit.

LPA toured the facility and observed all facility utilities to be on and operating without issue, food supply is sufficient, there is no immediate concern for residents in care. LPA toured the interior and exterior of the facility.

LPA spoke to the Licensee regarding the Incident Report submitted to Community Care Licensing Riverside Regional Office on 01/02/2024. The incident occurred on 12/31/2024. The Licensee has not submitted a report informing CCL of the incident that occurred, as of today’s date; 01/03/2025. LPA informed the Licensee that she has to submit a written report within seven (7) days of occurrence to CCL.

It was reported that Resident 1 (R1) reported an inappropriate sexual incident that occurred at the facility, by Staff 1 (S1). During the LPA’s visit, the LPA verified that S1 was not present at the facility. The Licensee informed the LPA that she fired him on 01/01/2025. The LPA requested a current and previous staff schedule, staff roster, resident roster, S1’s staff file, which would have included S1’s criminal background clearance.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: RUBIA'S TERRACE ARF
FACILITY NUMBER: 374602306
VISIT DATE: 01/03/2025
NARRATIVE
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Rubia informed the LPA that she does not have S1’s file because she gave S1’s file to S1 when she terminated S1. The Licensee terminated S1’s employment on 01/01/2025. The Licensee informed the LPA that S1 was employed from October 15th, 2024, to 01/01/2025. The LPA requested but did not obtain S1’s staff file or any pertinent files due to the Licensee not having any files pertaining to S1’s employment.

Based on the information obtained during today’s visit, there are two (2) deficiencies and civil penalties being cited per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted where a copy of this report was discussed, along with copies of the LIC809-D, 811, and Appeal Rights were provided to the Licensee, Mercedes Rubia and a copy of this report is left with her, as evidence by her signature.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/03/2025 02:55 PM - It Cannot Be Edited


Created By: Kathleen Banrasavong On 01/03/2025 at 11:32 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RUBIA'S TERRACE ARF
FACILITY NUMBER: 374602306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2025
Section Cited
HSC
80066(d)

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80066(d) All personnel records shall be retained for at least three years following termination of employment.
This requirement is not met as evidenced by:
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The Licensee, Mercedes Rubia stated that she will review the regulation cited and submit to the LPA a signed affidavit stating that she understands the regulation and will maintain employees' files per regulation standards. She stated that she will look through her records for any documentation of S1's employment and provide that to the LPA, if found.
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Based on the LPA's observation, interview, and record review, the licensee did not comply with the section cited above in the Licensee not having Staff 1 (S1)'s staff files, which poses a potential health, safety or personal rights risk to persons in care.
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Type A
01/02/2025
Section Cited
CCR80019(e)(2)

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"Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 80019(f)…"
This requirement is not met as evidenced by:
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The LPA verified that S1 does not work at the facility as of termination date 01/01/25. The Licensee stated that she will maintain a currrent LIC 500 and provided one to the LPA during her visit on 01/03/2025. S2 was removed from the facility during the LPA visit and The Licensee stated she will not return to work until S2's background is cleared.
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Based on interview and record review, the Licensee did not comply with the section cited above with S1 and S2 not being associated to the facility. This is a zero tolerance regulation and poses an immediate health, safety or personal rights risk to persons in care. A civil penalty will be assessed in the amount of $500 for a maximum of 5 days, per person.
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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:Jazmond D Harris
LICENSING EVALUATOR NAME:Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


LIC809 (FAS) - (06/04)
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