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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602639
Report Date: 03/21/2025
Date Signed: 03/21/2025 12:38:30 PM

Document Has Been Signed on 03/21/2025 12:38 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:PRINCESS BOARD & CARE CORP.FACILITY NUMBER:
374602639
ADMINISTRATOR/
DIRECTOR:		GUMABON, REMEDOR C.FACILITY TYPE:
735
ADDRESS:1203 EAST 1ST STREETTELEPHONE:
(619) 434-7343
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY: 4CENSUS: 4DATE:
03/21/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Staff Eleanor BautistaTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to continue a Required Annual Inspection which began on 03/17/2025. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Staff Eleanor Bautista.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, of whom all must be ambulatory. According to LIC602 Physician’s Reports, staff interviews, and LPA observation: During this annual inspection, there were a total of four (4) clients in care, and all were ambulatory, per their respective doctors. The facility’s license did not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present.

During this inspection, LPA toured the interior and exterior of the facility and inspected all common areas and bedrooms. LPA performed a welfare check on clients in care and interviewed multiple staff. LPA also reviewed the care and administrative records for all clients and the personnel and training files for all active staff. 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 and screens, toilets, and showers were working. Extra linens, hygiene, and Personal Protective Equipment (PPE) supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

The facility’s ambient internal temperature was complaint at 70 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen Sink was 107.8 F, Bathroom #1 Sink was 107.8 F, and Bathroom #2 Sink was 106.3 F. Appliances to preserve perishable food were also complaint in temperature: Kitchen Refrigerator was 38 F, Garage Refrigerator was 39 F, and both Kitchen and Garage Freezers were 0 F. There were at least (2) days of perishable food and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present and in good condition. [CONTINUED ON LIC809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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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Document Has Been Signed on 03/21/2025 12:38 PM - It Cannot Be Edited


Created By: Dang Nguyen On 03/21/2025 at 11:45 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PRINCESS BOARD & CARE CORP.
FACILITY NUMBER: 374602639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not conduct disaster drills at least quarterly for each shift. This posed a potential safety risk to 8 of 8 active staff (Staff #1 through Staff #8) and 4 of 4 clients (Client #1 through Client #4) in care.
POC Due Date: 04/21/2025
Plan of Correction
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Licensee has already performed a disaster drill on its PM shift during the current month. Licensee agreed to conduct two (2) more drills (one for AM shift and one for NOC), and to E-mail documentation of such to LPA, by the POC due date. Going forward, Licensee agreed to drill each shift at least once per quarter, and to vary the type of emergency covered from quarter to quarter.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: PRINCESS BOARD & CARE CORP.
FACILITY NUMBER: 374602639
VISIT DATE: 03/21/2025
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[CONTINUED FROM LIC 812]

The facility did not have a swimming pool (or similar body of water) or a fireplace. There were no open-faced heaters, toxic chemicals/poisons, or other hazardous objects accessible to clients. Smoke detectors, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. The facility's fire extinguisher was serviced within the last twelve (12) months. Medications were in their original pharmacy packaging and were stored in a locked area. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Per the Licensee, no firearms or ammunition were kept at the facility. Licensee presented proof of current business liability insurance and surety bond.

During a review of records, LPA observed, and manager interview confirmed: While Licensee performed multiple disaster drills over the past year, they fell short of the required frequency of one drill per shift, per quarter, as required by regulation. One (1) deficiency was cited per California Health and Safety Code (refer to the LIC809-D page). A Plan of Correction was jointly developed with the Licensee. LPA also issued one (1) Technical Violation regarding minor physical plant topics and Technical Assistance (TA) regarding medication destruction procedure.

An exit interview was conducted with Staff Eleanor Bautista, to whom a copy of this report, the LIC 809-D page, the LIC9102-TV page, the LIC9102-TA page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today's visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
LIC809 (FAS) - (06/04)
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