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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602960
Report Date: 07/12/2022
Date Signed: 07/12/2022 03:16:41 PM

Document Has Been Signed on 07/12/2022 03:16 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:PROMISING FUTURESFACILITY NUMBER:
374602960
ADMINISTRATOR:MARTHA J MORRISSEYFACILITY TYPE:
775
ADDRESS:109 E LEXINGTON AVETELEPHONE:
(619) 592-4850
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY: 72CENSUS: 26DATE:
07/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Mayreni Olea, Program AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit to follow up on two self- reported incidents, received by Community Care Licensing on 6/15/22 and 7/8/22. LPA was greeted and granted entry into the facility by Mayreni Olea, Program Administrator, with whom she discussed the purpose of the visit.

On 7/8/22, the facility submitted a self -reported incident regarding Client 1 (C1) pushing Client 2 (C2) (See LIC 811 Confidential Names to identify C1 & C2) that occurred on 7/6/22. C1 and C2 were outside in the courtyard area during the morning facility staff huddle. C1 was observed by Staff 1 (S1) and Staff (S2) (See LIC 811 Confidential Names to identify S1 & S2) extending their arms outward and pushing C2 forward onto a bench and onto the lap of Client 3 (C3), who was sitting on the bench. The push resulted in C2 scraping their knees on the ground and sustaining scrapes to both knees. S1 applied first aid immediately. C1 was immediately redirected and both clients were taken into their classrooms. Program Administrator stated that facility staff will assure that C1 and C2 are kept apart from each other. Program Administrator notified all appropriate parties. The El Cajon Police Department was contacted on their non-emergency phone line to report the incident. LPA conducted interviews with Program Administrator and facility staff. No deficiencies were cited regarding this incident.

On 6/15/22, the facility submitted a self - reported incident regarding Client 4 (C4) (See LIC 811 Confidential Names to identify C4) missing two doses of two separate medications at 12:00pm on 6/13/22. It was reported that Staff 3 (S3) (See LIC 811 Confidential Names to identify S3), failed to notify Program Administrator of C4's missed medications that were not taken at 12:00pm on 6/13/22. On 6/14/22, C4's missed medication doses were observed by Staff 4 (S4) from her review of the Medication Administration Record (MARS). S4 reported information to the Program Administrator. Per Program Administrator, she followed up with C4's responsible party and there were no health complications due to C4 missing the two doses of the separate medications. Program Administrator notified all appropriate parties. LPA reviewed client and staff records and Medication Administration Record (MARS). CONTINUED ON NEXT PAGE
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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: PROMISING FUTURES
FACILITY NUMBER: 374602960
VISIT DATE: 07/12/2022
NARRATIVE
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The following deficiency has been cited per Title 22, Division 6 of the California Code of Regulations (See LIC 809D).

An exit interview was conducted with Mayreni Olea, Program Administrator, to whom a copy of this report, LIC 809D, LIC 811 and the Licensee's Rights (LIC9058 01/16) were provided to Administrator
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/12/2022 03:16 PM - It Cannot Be Edited


Created By: Vicky Williamson On 07/12/2022 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PROMISING FUTURES
FACILITY NUMBER: 374602960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2022
Section Cited
CCR
82075(b)

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82075 Health-Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

The requirement was not met as evidenced by: Based on Medication Administration


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Program Administrator will assure that staff complete training with Nurse Consultant regarding administering medication to clients in care. A summary of the training and employee sign in sheet will be provided to LPA Williamson via email by POC date.
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Records for Client 4 (C4) and Staff 4 (S4) observation, medication doses for two separate medications were not given to C4 on 6/13/22 at 12:00 pm. due to S3 forgot to notify Program Administrator.
This poses a potential health and safety risk to clients in care.
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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:Simon Jacob
LICENSING EVALUATOR NAME:Vicky Williamson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022


LIC809 (FAS) - (06/04)
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