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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602308
Report Date: 03/03/2023
Date Signed: 03/03/2023 03:32:26 PM

Document Has Been Signed on 03/03/2023 03:32 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SAILS ALTA VISTAFACILITY NUMBER:
374602308
ADMINISTRATOR:LEONARD, KENNETHFACILITY TYPE:
735
ADDRESS:737 ALTA VISTA DRTELEPHONE:
(747) 888-6630
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 5CENSUS: 5DATE:
03/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Staff, Melanie GomezTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 3/3/2023 at 12:40 p.m.. LPA was granted entry by staff Melanie Gomez who was informed of the purpose of the visit. At the time of the visit there were (5) clients and (2) staff present. LPA The home is vendorized through San Diego Regional Center. The home is licensed to provide care to four (5) non-ambulatory clients, and is a two story home with (6) bedrooms and (3) bathrooms and all clients are between the ages of 18-59 ages. LPA observed the following:

Physical Plant: LPA observed for required accommodations in resident bedrooms and bathrooms. Physical plant, floors, windows, and doors are clean. Fixtures and furniture for an operational facility are present and in good repair. There is an adequate number of bedrooms present for the requested number of residents. Chemicals were observed locked in designated areas in the facility



Kitchen/Food Service: LPA observed food service area had the ability to serve food and cleanliness. Food supply was checked and met the requirement for a two day supply of perishable food and seven days of non-perishable food. Dishes, utensils, glasses are present.

Care & Supervision/Administration: Adequate staff are present for the supervision of residents. Emergency exiting plans, telephone numbers and personal rights were found posted in the facility.

Record Review and Resident/Staff Files: Current staff has Criminal Clearance and updated training along with CPR/First Aid Certification and complete files. The resident files were also found to be complet as well.

Medication: All resident medication was locked in a medication cart in the kitchen.

The following deficiencies were cited:
  • The facility garage and client bedroom #4 were found to be in disrepair due to a leak the facility had
  • The facility did not report this leak to licensing, or that the facility was found to have mold
  • The facility did not send notice of change of administrator within the required time frame

An exit interview was conducted where a copy of this report along with LIC 809-D pages and appeal rights were provided to staff, Melanie Gomez.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2023
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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Document Has Been Signed on 03/03/2023 03:32 PM - It Cannot Be Edited


Created By: Janira Arreola On 03/03/2023 at 02:47 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SAILS ALTA VISTA
FACILITY NUMBER: 374602308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with (2) rooms, the garage and the clients bedroom#4 that were in disrepair. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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The licensee shall send proof of repair to these rooms by the POC due date to the LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/03/2023 03:32 PM - It Cannot Be Edited


Created By: Janira Arreola On 03/03/2023 at 02:50 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SAILS ALTA VISTA
FACILITY NUMBER: 374602308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)(1)
(e) The items below shall be reported to the licensing agency within 10 working days following the occurrence.

(1) The organizational changes specified in Section 80034(a)(2).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above with administrator change that was not sent to Licenseing. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2023
Plan of Correction
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The licensee must send a change of adminsitrator request along with required documentation to LPA by the POC due date.
Type B
Section Cited
CCR
80061(b)(1)(E)
80061 Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency...
(1) Events reported shall include the following:
(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above due to the facility staff reporting that the facility was found to have mold in the facility garage. This posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2023
Plan of Correction
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The licensee shall send a written statement stating that they have read and understood the section cited above and should report any similar incident to licensing agency. This statement shall be dated and signed and shall be sent to the LPA by the POC due date.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023


LIC809 (FAS) - (06/04)
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