374602935-12-6-2023-08-AS-DSEA-CYA226-20231206160014

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602935
Report Date: 12/06/2023
Date Signed: 12/06/2023 05:03:48 PM

Document Has Been Signed on 12/06/2023 05:03 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:	D'AMORE HOMES (RCFE)		FACILITY NUMBER:	374602935
ADMINISTRATOR:	AGUINALDO, HONESTO P.		FACILITY TYPE:	740
ADDRESS:	2996 DARDAINA		TELEPHONE:	(619) 512-1105
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92139
CAPACITY:	6	CENSUS: 6	DATE:	12/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Amor Aguinaldo		TIME COMPLETED:	04:10 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 and was granted entry into the facility by Joy Millan, Caregiver, to whom she disclosed the purpose of the visit. Administrator, Amor Aguinaldo, was contacted via telephone and arrived a short time later. According to the facility’s license, the facility is licensed for six (6) residents, one (1) of whom may be non-ambulatory and one (1) bedridden. During today’s inspection, there were six (6) clients residing in the facility. The facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by administrator, toured the interior and exterior of the facility. The facility was clean, sanitary, and in good repair. Resident rooms had ample space and required furnishings. Pathways were free of obstruction and slip hazards. Doors, windows, and screens were present and sinks and toilets were in working order. Hygiene supplies and Personal Protective Equipment were present. The facility had sufficient space and equipment to facilitate visitation, meetings, and client activities. Hot water temperature in bathroom sink accessible to residents measured at 120 degrees F. No pools or bodies of water were observed on the premises. Per the administrator, 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 serviced within the last 12 months. First aid kit was complete and readily accessible. There were no sharp objects, fireplaces, or open-faced heaters accessible to clients. However, LPA observed Microban disinfectant cleaner and Clorox toilet bowl cleaner in the resident bathroom in an area that was accessible to residents in care. LPA interviewed staff and clients. LPA also reviewed staff and client records/files. The files that were reviewed by LPA contained required documents. Confidential records were stored in locked areas.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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: D'AMORE HOMES (RCFE)	FACILITY NUMBER: 374602935
	VISIT DATE: 12/06/2023

NARRATIVE

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Required licensing postings were observed in visible areas of the facility.

Deficiency is cited per California Code of Regulations, Title 22, on the attached LIC 809-D. A plan of correction was jointly developed with the administrator. An exit interview was conducted with Amor Aguinaldo, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit. Her signature on this report confirms receipt of copies of the documents.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/06/2023 05:03 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: D'AMORE HOMES (RCFE)	FACILITY NUMBER: 374602935
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Disinfectants, cleaning solutions, poisons, firearms, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above which posed a potential health and safety risk to 6 of 6 persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Administrator immediately stored the items in a locked cabinet. Administrator expressed that a new cabinet will be installed in the bathroom in which toxic chemicals can be stored and made inaccessible to clients. Administrator offered to provide staff training on proper storage of toxic chemicals and to provide proof of training to Community Care Licensing by the POC due date of 12/15/2023.

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: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

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