374602806-3-14-2024-08-AS-DSEA-D3CRVH-20240314132135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602806
Report Date: 03/14/2024
Date Signed: 03/14/2024 04:35:30 PM

Document Has Been Signed on 03/14/2024 04:35 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:	HOME SWEET HOME CARE		FACILITY NUMBER:	374602806
ADMINISTRATOR:	NONAY, NORMA D.		FACILITY TYPE:	740
ADDRESS:	6811 FUJI STREET		TELEPHONE:	(619) 472-9205
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92139
CAPACITY:	6	CENSUS: 2	DATE:	03/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Norma Nonay, Licensee		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced required annual inspection. LPA identified herself, was granted entry into the facility, and met with Norma Nonay, Licensee, to whom LPA disclosed the purpose of the visit. According to the facility’s license, the facility is licensed for six (6) residents, all of whom must be ambulatory. During today’s inspection, there were two (2) residents in care. LPA, accompanied by licensee, toured the interior and exterior of the facility. Pathways were free of obstruction and slip hazards. Doors, windows, and screens were present and sinks and toilet were in working order. Hygiene supplies and Personal Protective Equipment were present. The facility had sufficient space and equipment to facilitate visitation, meetings, and activities. Hot water temperature in bathroom sink in bathroom that is used by residents measured at 110.8 degrees Fahrenheit. There were no sharp objects or open-faced heaters accessible to residents. A fireplace with appropriate screening was observed in the living area of the home. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms and facility telephone were in working order; however, the carbon monoxide detector that was present in the home did not work. Refrigerator and freezer were operational. 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. Medications were labeled, as required, and stored in locked cabinets. First aid kit was complete and readily accessible.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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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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: HOME SWEET HOME CARE	FACILITY NUMBER: 374602806
	VISIT DATE: 03/14/2024

NARRATIVE

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LPA interviewed staff and client who were present. LPA also reviewed staff and client records/files. Staff 1's (S1) file contained proof of current first aid training, but staff did not have current CPR training. Confidential records were stored in a secured area.

Deficiencies are being cited and a technical advisory provided today. A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Norma Nonay, to whom a copy of this report, the LIC 809-D, LIC 9102TA, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/14/2024 04:35 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HOME SWEET HOME CARE	FACILITY NUMBER: 374602806
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. 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 1 of 1 carbon monoxide detector did not work, which poses a potential safety risk to persons in care.
	POC Due Date: 03/21/2024
	Plan of Correction
1 2 3 4	Licensee offered to purchase and install a new carbon monoxide detector and provide proof of installation to Community Care Licensing by the POC due date.

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 of 1 staff (S1), which poses a potential health risk to persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	Licensee offered to attend and complete CPR training and provide proof of training/certification to Community Care Licensing by the POC due date.

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	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC809 (FAS) - (06/04)

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