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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602950
Report Date: 12/31/2024
Date Signed: 01/02/2025 09:12:52 AM

Document Has Been Signed on 01/02/2025 09:12 AM - 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 RESIDENCESFACILITY NUMBER:
374602950
ADMINISTRATOR/
DIRECTOR:		BROCKMEIER, ROSEMARIEFACILITY TYPE:
740
ADDRESS:15260 AMALIATELEPHONE:
(858) 366-8787
CITY:SAN DIEGOSTATE: CAZIP CODE:
92129
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Caregiver Reyner GrangosTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Reyner Grangos. Licensee Azila Ortiz arrived during the visit and introduced herself to the LPA. Administrator Jeremy Bagaoisan also arrived during the visit and assisted the LPA. The facility was licensed for a capacity of six (6) non-ambulatory residents, with one bedridden approved in bedroom number four (4). The facility also had an approved hospice waiver for four (4) residents.

The LPA, accompanied by caregiver, toured the interior and exterior of the facility, and inspected resident bedrooms. The facility was clean, and sanitary. Pathways were free of obstruction and slip hazards. The exterior perimeter fence was observed to be in disrepair. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, visitation, meetings, and resident 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 residents, and medications were labeled and locked.

No pools, nor bodies of water were observed on the premises. Per staff, no firearms nor ammunition were kept at the facility. Carbon monoxide detectors, emergency lighting, and fire extinguisher(s) were present and operational. Required licensing postings were observed in visible areas of the facility.

The LPA conducted interviews and reviewed staff and resident files. The LPA technical advise and deficiencies discovered during the the review of records were cited in an LIC 809D form, and a Plan of Correction was jointly formulated with Administrator Bagaoisan.

An exit interview was conducted with Administrator Bagaoisan, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058), were provided via email. An email read receipt confirms the report was received by the administrator.
Lizzette TellezTELEPHONE: (619) -76-2351
Sabel MartinezTELEPHONE: (619) 767-2301
DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024
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 01/02/2025 09:12 AM - 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: 12/31/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of records and an interview, the licensee did not comply with the section cited above in 3 out of 3 staff, which posed a potential health, safety or personal rights risk to 6 persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator agreed to provide annual training in dementia care, postural supports, restricted health conditions, hospice care, infection control training, personal rights training, and interaction with emergency personnel, to all staff by 1/31/2025. The administrator agreed to submit training log, or certificates to the LPA by 1/31/25.
Section Cited
87307 Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the exterior perimeter fence was in disrepair, the licensee did not comply with the section cited above in which posed a potential health, safety or personal rights risk to 6 persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Adminstrator agreed to fix the portion of the fence that was in disrepair by 1/31/25, and provide photographic proof to the LPA by 1/31/25.
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 TellezTELEPHONE: (619) -76-2351
Sabel MartinezTELEPHONE: (619) 767-2301

DATE: 12/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2024

LIC809 (FAS) - (06/04)
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