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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602563
Report Date: 11/04/2024
Date Signed: 11/04/2024 01:07:29 PM

Document Has Been Signed on 11/04/2024 01:07 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:PEARLS COVEFACILITY NUMBER:
374602563
ADMINISTRATOR/
DIRECTOR:		AERIAKA JACOBSFACILITY TYPE:
735
ADDRESS:5899 TOOLEY STREETTELEPHONE:
(619) 266-0752
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 4TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
11/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Diana Diaz, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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 Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a health and safety check on a case management visit. LPA Lopez identified herself and was granted entry by caregiver Roxie Dukes and Administrator Diana Diaz. LPA discussed the purpose of the visit with Administrator Diaz.

This visit was in response to a phone call received by Licensee Aerika Jacobs, on Friday, November 1, 2024. Licensee notified LPA that a Special Incident Report (SIR) to the San Diego Regional Office would be forthcoming. Licensee notified LPA that an incident had transpired that morning on Friday, November 1, 2024, with client #1 (C1 - see confidential names list) who had a behavioral episode which led to self - injurious behavior. The facility made proper notifications to San Diego Police Department, Crisis Team, Orange County Regional Center (OCRC), clients responsible party, Physician, Behavioral Consultant and to the Department.

During today's visit LPA Lopez toured the facility, spoke with staff, and requested and obtained relevant documents pertinent to this incident. LPA Lopez verified with staff that C1 was not feeling themselves and acted out by physically self-harming themselves and drinking another clients bottle of mouthwash. Additional records showed that C1 does have a history of self - injurious behaviors.

LPA informed Administrator Diana Diaz that there may be further follow-up telephone calls or visits for this incident. A deficiency was observed and cited during today’s visit.

A plan of correction was jointly developed and and exit interview was conducted with Administrator Diana Diaz and a copy of this report, LIC811 and Licensee Appeal Rights (LIC9058) were provided to Administrator Diaz at the conclusion of the visit. The signature below confirms that the documents were received.
Robyn ClarkTELEPHONE: (619) 767-2312
Carmen LopezTELEPHONE: (619) 767-2301
DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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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Document Has Been Signed on 11/04/2024 01:07 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: PEARLS COVE
FACILITY NUMBER: 374602563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement was not met as evidence by,
Deficient Practice Statement
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POC Due Date: 11/04/2024
Plan of Correction
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The facility immediately removed the hygiene items from all the clients bathrooms and locked them in a cabinet. Cleared during the visit.
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.
Robyn ClarkTELEPHONE: (619) 767-2312
Carmen LopezTELEPHONE: (619) 767-2301

DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024

LIC809 (FAS) - (06/04)
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