374602940-11-7-2024-08-AS-DNGN-DASVSN-20241107154150

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602940
Report Date: 11/07/2024
Date Signed: 11/07/2024 03:43:20 PM

Document Has Been Signed on 11/07/2024 03:43 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:	SERRA MESA GUESTS HOME II		FACILITY NUMBER:	374602940
ADMINISTRATOR/ DIRECTOR:	WILFREDO SALAZAR		FACILITY TYPE:	740
ADDRESS:	566 PARKWOOD DRIVE		TELEPHONE:	(619) 944-3018
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92139
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 1	DATE:	11/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Caregiver Celina Samonte and Licensee Evelyn Salazar		TIME VISIT/ INSPECTION COMPLETED:	04:00 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) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Celina Samonte. LPA then met with Licensee Evelyn Salazar, who arrived later during the visit. According to the facility’s license, the facility has a maximum capacity of six (6) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. According to care records, staff interviews, and LPA observation: During today’s inspection, there was a total of one (1) resident in care, Resident #1 (R1), who was non-ambulatory. [See LIC811 Confidential Names list for a description of select person identifiers used in this report.] The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present. During today’s visit, LPA performed a welfare check, interviewing R1 and multiple staff. LPA reviewed R1’s care records and personnel files for multiple staff. LPA, accompanied by the Licensee, also toured the interior and exterior of the facility, and inspected all common areas and bedrooms. 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 working. Extra linens, hygiene supplies, and Personal Protective Equipment (PPE) were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Inside the facility was a cabinet which contained centrally stored medications. At the time of LPA’s arrival, the doors of this cabinet were closed but not locked. (This cabinet was subsequently locked by staff during LPA’s visit.) Inside the facility’s garage refrigerator, LPA observed, unlocked/accessible, three (3) packages of suppositories. [CONTINUED ON LIC 809-C, 1 of 2]

Lizzette Tellez	TELEPHONE: (619) 767-2351
Dang Nguyen	TELEPHONE: (619) 210-9024
	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 03:43 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: SERRA MESA GUESTS HOME II	FACILITY NUMBER: 374602940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA measurement via thermometer, Licensee did not maintain hot water temperature controls to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degrees F and not more than 120 degrees F. This posed an immediate safety risk to 1 of 1 residents (R1) in care.
	POC Due Date: 11/07/2024
	Plan of Correction
1 2 3 4	During today's visit, adjustments were made to the facility's water heater, such that hot water at all taps used by residents were brought back into the range required by regulation. This action resolved the deficiency.

Section Cited

Storage Space

(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 observation and staff interview, Licensee did not ensure that cleaning solutions and other items that could pose a danger if readily available to clients were stored where inaccessible to clients. This posed an immediate health and safety risk to 1 of 1 clients (R1) in care.
	POC Due Date: 11/07/2024
	Plan of Correction
1 2 3 4	During today's visit, the cleaning solutions / hazardous items which were the basis for this deficiency were handed to facility staff to lock away. This action resolved the immediate risk. Licensee agreed to conduct retraining with its direct care staff on all items which could pose a hazard to residents with dementia, and to E-mail the training sign-in sheet to LPA, by the 12/07/2024.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lizzette Tellez	TELEPHONE: (619) 767-2351
Dang Nguyen	TELEPHONE: (619) 210-9024
	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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Document Has Been Signed on 11/07/2024 03:43 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: SERRA MESA GUESTS HOME II	FACILITY NUMBER: 374602940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Infection Control Requirements

(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around residents and annually thereafter. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and interviews, Licensee did not ensure that 5 of 5 facility staff (S1 through S5) were trained in the proper use of all required PPE annually. This posed a potential health risk to persons in care.
	POC Due Date: 12/07/2024
	Plan of Correction
1 2 3 4	Licensee agreed to conduct PPE training for all current staff. The training will include hands-on practice and will cover: a) how perform an N-95 seal check, b) how to correctly don and doff surgical masks, N-95 respirators, face shields, gowns, and gloves, and c) how to set up and manage an isolation bedroom. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date.

Section Cited

Other Provisions

(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and interviews, Licensee did not ensure that 5 of 5 active staff (S1 through S5) received annual training on the facility's written emergency/disaster plan. This posed a potential safetly risk to persons in care.
	POC Due Date: 12/07/2024
	Plan of Correction
1 2 3 4	Licensee agred to update its existing LIC610E Emergency/Disaster Plan, and then retrain all current staff on it. Licensee agreed to E-mail the training sign-in sheet to LPA, 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.

Lizzette Tellez	TELEPHONE: (619) 767-2351
Dang Nguyen	TELEPHONE: (619) 210-9024
	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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Document Has Been Signed on 11/07/2024 03:43 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: SERRA MESA GUESTS HOME II	FACILITY NUMBER: 374602940
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87465 Incidental Medical and Dental Care: “(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 was not met, as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and manager interview, Licensee did not ensure that centrally stored medicines were kept in a safe and locked place that is not accessible to persons other than employees responsible for them. This posed an immediate health and safety risk to 1 of 1 residents (R1) in care.
	POC Due Date: 11/07/2024
	Plan of Correction
1 2 3 4	During today’s visit, facility staff locked the medication cabinet and secured the loose suppositories for destruction, resolving the immediate risk. Licensee agreed to retrain current staff on requirements/expectations around ensuring centrally stored medications locked such that they are not freely accessible to anyone other than those facility employees responsible for medications. Licensee agreed to E-mail the training sign-in sheet to LPA, by 12/07/2024.

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.

Lizzette Tellez	TELEPHONE: (619) 767-2351
Dang Nguyen	TELEPHONE: (619) 210-9024
	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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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: SERRA MESA GUESTS HOME II	FACILITY NUMBER: 374602940
	VISIT DATE: 11/07/2024

NARRATIVE

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[CONTINUED FROM LIC 809] Interview of facility manager showed that the suppositories belonged to a former resident. (The suppositories were subsequently removed and handed to Licensee for destruction.) In the facility’s backyard, LPA observed two (2) former juice bottles which had been re-purposed to hold liquid cleaning chemicals; one was purple in color, and one was clear. Staff interviews confirmed these bottles contained cleaning chemicals, to include bleach. The original juice labels were still on these bottles, and the bottles were left in the open and accessible. (These chemicals were subsequently removed and handed to staff to be correctly labeled and locked away). According to their latest LIC602 Physician’s Report (dated 10/24/2024), R1’s physician wrote that R1 had Alzheimer’s Disease and Dementia, that they were confused/disoriented, and that they required staff assistance to store and take their prescribed medications.

The facility’s ambient internal temperature was complaint at 71 F. Hot water at taps accessible to clients were initially too hot, when compared to the temperature range described in regulation: Kitchen Sink was 129.4 F, Bathroom #1 Sink was 131.9 F, Bathroom #2 Sink was 133.2 F, and Bathroom #3 Sink was 133.6 F. (During today’s visit, adjustments were made to the facility’s water heater to bring all these taps back into the compliant temperature range). Appliances to preserve perishable food were compliant in temperature: Kitchen and Garage Refrigerators were both below 40 F. Kitchen and Garage Freezers were both 0 F or colder. There were at least (2) days of perishable food and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present.

Confidential records were stored in locked areas. Per the Licensee, no firearms or ammunition were kept at the facility. No pools or bodies of water observed on the premises. The facility's fireplace was screened. There were no open-faced heaters accessible to residents. Smoke detectors, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. The facility’s fire extinguishers were serviced within the last twelve (12) months. Required licensing postings were observed in visible areas of the facility. Licensee presented proof of current business liability insurance.

During a review of training records, LPA observed, and manager interview confirmed: Licensee did not have proof that active Staff #1 (S1) through Staff #5 (S5) had received training on the facility’s written Emergency Disaster Plan within the last year, as was required. Also, Licensee did not have proof that S1 through S5 had received training on Personal Protective Equipment (PPE) within the last year, as was required.

[CONTINUED ON LIC 809-C, 2 of 2]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	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

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: SERRA MESA GUESTS HOME II	FACILITY NUMBER: 374602940
	VISIT DATE: 11/07/2024

NARRATIVE

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[CONTINUED FROM LIC 809-C, 1 of 2]

Four (4) deficiencies was cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding tight-fitting covers on trash cans (refer to the LIC9102-TV page).

An exit interview was conducted with Licensee Evelyn Salazar, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today's visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	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

LIC809 (FAS) - (06/04)

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