374602807-1-30-2024-08-AS-NPED-CZYM8F-20240130082302

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602807
Report Date: 01/26/2024
Date Signed: 01/30/2024 08:24:06 AM

Document Has Been Signed on 01/30/2024 08:24 AM - 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:	CLAIREMONT GUEST HOME		FACILITY NUMBER:	374602807
ADMINISTRATOR:	ANDRADE, MAUREEN P.		FACILITY TYPE:	740
ADDRESS:	3476 IDLEWILD WAY		TELEPHONE:	(858) 273-8845
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92117
CAPACITY:	6	CENSUS: 6	DATE:	01/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Administrator, Jimmy Andrade		TIME COMPLETED:	06:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility by Staff, Roxane De Guzman. Administrator, Jimmy Andrade and arrived during the visit.

LPA, accompanied by staff, 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. Resident bedrooms contained the required furnishings. Doors, windows and 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 resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 120 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, and/or fireplaces accessible to residents. Medications were centrally stored but not locked. There was a padlock on the cabinet but it was not locked. Staff locked the medications during the visit.

No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed multiple staff and residents. LPA reviewed multiple staff and resident records/files. Resident records did not contain all required documentation.

A deficiency was observed and cited during today's annual inspection. A Technical Advisory was issued. An exit interview was conducted with Roxane De Guzman to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

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 01/30/2024 08:24 AM - 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: CLAIREMONT GUEST HOME	FACILITY NUMBER: 374602807
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and interviews, the licensee did not lock medications for 6 out of 6 residents [R1-R6] which poses an immediate health and safety risk to persons in care.
	POC Due Date: 01/27/2024
	Plan of Correction
1 2 3 4	Staff locked the medication cabinet, removing the immediate threat to correct the deficiency. Licensee agreed to conduct In-Service training regarding locking medications and submit proof of training within 2 weeks.

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC809 (FAS) - (06/04)

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