374602722-8-11-2023-08-AS-RGAZ-CULVSW-20230811164214

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602722
Report Date: 08/11/2023
Date Signed: 08/11/2023 04:42:19 PM

Document Has Been Signed on 08/11/2023 04:42 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:	INDEPENDENCE FIRST, INC.-BUENA VISTA		FACILITY NUMBER:	374602722
ADMINISTRATOR:	AGUINALDO, LAIKA		FACILITY TYPE:	735
ADDRESS:	2519 BUENA VISTA AVE		TELEPHONE:	(619) 518-7375
CITY:	LEMON GROVE	STATE: CA	ZIP CODE:	91945
CAPACITY: 6		CENSUS: 5	DATE:	08/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Josephine Hazelbach		TIME COMPLETED:	04:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Riza Alvarez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Josephine Hazelbach, Direct Support Professional (DSP) to whom LPA discussed the purpose of the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) ambulatory, developmentally-disabled adults. During today’s inspection, there was a total of five (5) clients in care, all of whom are ambulatory.

LPA, accompanied by J Hazelbach, toured the interior and exterior of the facility, and inspected each room. 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, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant at 79 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 113.1 F, bathroom #1 sink was 114 F and bathroom #2 sink was 115 F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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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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: INDEPENDENCE FIRST, INC.-BUENA VISTA	FACILITY NUMBER: 374602722
	VISIT DATE: 08/11/2023

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per J Hazelbach, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and clients present. LPA interviews did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Files reviewed contained the required documents. Confidential records were stored in locked areas. J Hazelbach presented proof of current/active business liability insurance and surety bond.

Deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with J Hazelbach.

An exit interview was conducted with DSP Josephine Hazelbach, to whom copies of this report, the LIC 809-D page, and the Application/Licensee Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/11/2023 04:42 PM - It Cannot Be Edited

Created By: Riza Gloria Alvarez On 08/11/2023 at 04:22 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: INDEPENDENCE FIRST, INC.-BUENA VISTA	FACILITY NUMBER: 374602722
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2023

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in three (3) out of eleven (11) window screens which poses a potential health risk to persons in care.
	POC Due Date: 09/11/2023
	Plan of Correction
1 2 3 4	Licensee will submit to CCLD proof of repair of three (3) window screens, such as copy of receipt for purchase of repair materials, and photos of repaired window screens.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Denise Powell

LICENSING EVALUATOR NAME:

Riza Gloria Alvarez

LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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