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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602728
Report Date: 10/10/2024
Date Signed: 10/10/2024 01:34:43 PM


Document Has Been Signed on 10/10/2024 01:34 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: 0DATE:
10/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Phyllis Bolton, LicenseeTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit for a Plan of Correction clearance and re-issue a citation. LPA Lopez identified herself and was allowed entry by Licensee, Phyllis Bolton. LPA met with Licensee Bolton and discussed the purpose of the visit.

On 08/06/2024, the facility was issued three deficiencies regarding two staff (S1 and S2) who did not have their Health Screening form on file, bedding did not have mattress protectors/pads, and updated information for clients Record of Client’s Safeguarded Cash Resources (LIC405).

During today’s visit, LPA reviewed both staff Health Screening forms; and facility did obtain mattress protector/pads for bedding. Licensee did hot have the updated forms, Records of Client’s Safeguarded Cash Resources, for clients on file. As such, two (2) deficiencies have been corrected and cleared and one deficiency was re-issued.

An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee Phyllis Bolton at the conclusion of the visit. The signature below confirms receipt of these documents.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
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 10/10/2024 01:34 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: RESIDENT'S PALACE, THE
FACILITY NUMBER: 374602728

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2024
Section Cited
CCR
80026(h)

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(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, ...

This requirement is not met as evidenced by:
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During the visit on 8/06/2024, the cash resources binders were on the facility premise but they were not accurate. Administrator had agreed to ensure Licensee updates the Records of Client's/Resident's Safeguard Cash Resources (LIC405) and notify LPA via email by POC due date, 08/12/2024.
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 client cash resources binder(s) were not updated during the visit on 08/06/24 which posed a potential personal rights risk to persons in care.
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During today's visit 10/10/24, Licensee had provided the forms to the current care providers for clients but did not obtain copies. Licensee will obtain copies and submit the July/August client Cash Resource Form to LPA by POC due date, 10/18/24.

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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: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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