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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602930
Report Date: 11/07/2024
Date Signed: 11/07/2024 03:58:10 PM

Document Has Been Signed on 11/07/2024 03:58 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:LUCIE'S SHADY RESTFACILITY NUMBER:
374602930
ADMINISTRATOR/
DIRECTOR:
ZACHAY, GILBERTFACILITY TYPE:
740
ADDRESS:7142 BOBHIRDTELEPHONE:
(619) 741-4460
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Administrator Gilber Zachay TIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Iby Strong and David Roman conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Administrator Gilbert Zachay. According to the facility’s license, the facility has a maximum capacity of six clients, of whom all may be non-ambulatory and one of which may be bedridden.

LPAs toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to client. Medications were labeled, as required, and stored in locked areas. Water temperature was measured at 120 degrees F.



No pools or bodies of water on the premises. Per Gilbert, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible.

Resident records reviewed had required documentation, Resident 1 (R1) did not have a physician report but Gilbert states it was created though not available at this time. Staff records reviewed did not contain one first aid certificate for Staff 2 (S2).

One deficiency was cited today for S2 first aid training, and one technical violation was issued for no medical assessment for R1.

An exit interview was conducted with Administrator Gilbert Zachay, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22), LIC 809-D and LIC 9201 were provided during the visit.

Simon JacobTELEPHONE: (619) -76-2306
Iby StrongTELEPHONE: 619-481-0846
DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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 11/07/2024 03:58 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: LUCIE'S SHADY REST

FACILITY NUMBER: 374602930

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed the licensee did not comply with the section cited above in one of two staff present which poses safety risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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Licensee agrees to provide first aid training to staff by plan of correction date and provide LPA proof of such.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Simon JacobTELEPHONE: (619) -76-2306
Iby StrongTELEPHONE: 619-481-0846

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024

LIC809 (FAS) - (06/04)
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