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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602728
Report Date: 07/05/2023
Date Signed: 07/05/2023 04:58:47 PM

Document Has Been Signed on 07/05/2023 04:58 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:RESIDENT'S PALACE, THEFACILITY NUMBER:
374602728
ADMINISTRATOR:PHYLLIS BOLTONFACILITY TYPE:
735
ADDRESS:8090 BROOKHAVEN RDTELEPHONE:
(619) 434-9231
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 4CENSUS: 4DATE:
07/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Licensee Phyllis BoltonTIME COMPLETED:
05:05 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 Licensee Phyllis Bolton, to whom LPA discussed the purpose of the visit.

According to the facility’s license, the facility has a maximum capacity of four (4) developmentally disabled adults, all of whom must be ambulatory. During today’s inspection, two (2) clients are in care, two (2) clients are at day program.

LPA, accompanied by Licensee, 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, screens, 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 76 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 113.8 F, bathroom #1 sink was 112.2 F and bathroom #2 sink was 112.2 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: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: RESIDENT'S PALACE, THE
FACILITY NUMBER: 374602728
VISIT DATE: 07/05/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per Licensee, 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 purchased today. Licensee provided LPA with a copy of the receipt of purchase. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Licensee presented proof of current/active business liability insurance and surety bond.

LPA interviewed Licensee and staff present. Clients present are non-verbal. LPA interviews did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Staff records/files did not contain several required documents. Clients' personal and incidental (P&I) cash resources records and cash were not at the facility. Per Licensee, the records and cash are at their residence as they are being updated.

Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). A Plan of Correction was jointly developed with Licensee Bolton.

An exit interview was conducted with Licensee Bolton, to whom copies of this report, LIC 809-D pages, and the 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: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/05/2023 04:58 PM - It Cannot Be Edited


Created By: Riza Gloria Alvarez On 07/05/2023 at 04:34 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: RESIDENT'S PALACE, THE
FACILITY NUMBER: 374602728

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in four (4) out of four (4) facility staff which poses a potential health risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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2
3
4
Licensee will email CCL copies of health screening for four (4) facility staff.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review), the licensee did not comply with the section cited above in two (2) out of four (4) facility staff, which poses a potential health risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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Licensee will email CCL copies of TB test documents for two (2) facility staff.
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: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document is an Amendment of Original Document on 10/17/2023 11:35 AM


Created By: Riza Gloria Alvarez On 07/05/2023 at 04:34 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: RESIDENT'S PALACE, THE
FACILITY NUMBER: 374602728

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Health-Related Services
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
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: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023


LIC809 (FAS) - (06/04)
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