374602940-11-29-2023-08-AS-DSEA-CY33R9-20231129172819

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602940
Report Date: 11/29/2023
Date Signed: 11/29/2023 05:28:27 PM

Document Has Been Signed on 11/29/2023 05:28 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:	WILFREDO SALAZAR		FACILITY TYPE:	740
ADDRESS:	566 PARKWOOD DRIVE		TELEPHONE:	(619) 944-3018
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92139
CAPACITY:	6	CENSUS: 5	DATE:	11/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Evelyn Salazar, Administrator		TIME COMPLETED:	04:30 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 Evelyn Salazar, Administrator, who arrived at the facility a short time later. LPA disclosed the purpose of the visit. According to the facility’s license, the facility is licensed for six (6) residents, all of whom may be non-ambulatory. During today’s inspection, there were five (5) residents in care. 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 and in good repair. Pathways were free of obstruction and slip hazards. Non-skid mats were present in resident bathrooms. Equipment inspected was in working order. Hygiene supplies and Personal Protective Equipment were present. The facility had sufficient space and equipment to facilitate visitation, meetings, and resident activities. The facility’s internal temperature was 72 degrees F. Hot water temperature in bathroom sink accessible to residents was 120 degrees F. There were no sharp objects, fireplaces, or open-faced heaters accessible to residents; however, AJAX powder was observed in an unlocked cabinet below the sink in a bathroom accessible to a resident who has a diagnosis of dementia. 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, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. LPA interviewed staff and residents. LPA also reviewed staff and resident records/files. LPA observed that Resident 2 (R2) was admitted into the facility in May 2023; however, R2’s admission agreement was not signed by R2 or R2’s responsible party.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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: SERRA MESA GUESTS HOME II	FACILITY NUMBER: 374602940
	VISIT DATE: 11/29/2023

NARRATIVE

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Confidential records were stored in a locked file cabinet, and required licensing postings were observed in visible areas of the facility.

Deficiencies are cited per California Code of Regulations, Title 22, on the attached LIC 809-D. Technical advisories were also provided to the administrator.

Plans of Correction were jointly developed with the administrator. An exit interview was conducted with Evelyn Salazar, to whom a copy of this report, the LIC 809-D, LIC 9102TAs, the LIC 811 Confidential Names List, 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: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/29/2023 05:28 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: 11/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

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, the licensee did not comply with the section cited above with 1 toxic cleaning powder which posed a potential health risk to 1 of 5 persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	The AJAX disinfectant powder was immediately moved and stored in a locked area. Administrator offered to conduct staff training on proper storage of toxic chemicals and other harmful items for all staff and provide proof of training to Community Care Licensing by the POC due date.

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. 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 out of 5 admission agreements reviewed which posed a potential personal rights risk to persons in care.
	POC Due Date: 12/13/2023
	Plan of Correction
1 2 3 4	Administrator offered to ensure that the R2's admission agreement is signed and a copy of the signed agreement is provided 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: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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