374602950-12-18-2023-08-AS-SMAZ-CYMUTS-20231218145224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602950
Report Date: 12/18/2023
Date Signed: 12/18/2023 02:52:29 PM

Document Has Been Signed on 12/18/2023 02:52 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:	RB SENIOR RESIDENCES		FACILITY NUMBER:	374602950
ADMINISTRATOR:	BROCKMEIER, ROSEMARIE		FACILITY TYPE:	740
ADDRESS:	15260 AMALIA		TELEPHONE:	(858) 366-8787
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92129
CAPACITY:	6	CENSUS: 6	DATE:	12/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Administrator Jeremy Bagaoisan		TIME COMPLETED:	03:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection Visit. The LPA introduced himself and disclosed the purpose of the visit with Administrator Jeremy Bagaoisan. The facility was licensed for a capacity of six (6) residents, and at the time of the visit, the facility had a census of six (6).

Accompanied by Administrator Bagaoisan, the LPA toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Resident bedrooms contained the required furnishings. The facility had sufficient space and equipment to facilitate dining, visitation, meetings, and client activities.

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 toxic chemicals/poisons accessible to clients. Medications were labeled, and stored in locked areas.

No pools, nor bodies of water were observed on the premises. Per staff, no firearms or ammunition were kept at the facility. Carbon monoxide detectors, fire extinguisher(s), and a first aid kit were readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and reviewed multiple staff and resident records/files. Staff files revealed 1st Aid Certificates were not maintained at the facility for Staff #1, #2, and #3. A plan of correction was jointly formulated with Administrator Bagaoisan.

An exit interview was conducted with Bagaoisan, to whom a copy of this report, LIC 809D, and the Licensee/Appeal Rights (LIC9058), were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

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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Document Has Been Signed on 12/18/2023 02:52 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: RB SENIOR RESIDENCES	FACILITY NUMBER: 374602950
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (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
1 2 3 4	Based on interview and review of records, the licensee did not comply with the section cited above in 3 out of 3 staff (Staff #1, #2, and #3) which poses/posed a potential health, safety or personal rights risk to 6 of 6 persons in care.
	POC Due Date: 01/17/2024
	Plan of Correction
1 2 3 4	Administrator agreed to provided 1st aid training for all staff, and submit certificates to the LPA, by 1/17/2024.

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.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

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