374602972-1-22-2024-08-AS-AROS-CZR2GL-20240122162319

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602972
Report Date: 01/22/2024
Date Signed: 01/22/2024 04:23:28 PM

Document Has Been Signed on 01/22/2024 04:23 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:	PLAZA VILLAGE SENIOR LIVING		FACILITY NUMBER:	374602972
ADMINISTRATOR:	SHETLER, MARIA		FACILITY TYPE:	740
ADDRESS:	950 L AVE		TELEPHONE:	(619) 474-4844
CITY:	NATIONAL CITY	STATE: CA	ZIP CODE:	91950
CAPACITY:	85	CENSUS: 62	DATE:	01/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:			TIME COMPLETED:	04:35 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) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers was granted entry into the facility by Executive Director Maria Shetler, after identifying herself and stating the purpose of the inspection. The facility serves eighty-five elderly residents, age 60 and above, 47 of whom may be non-ambulatory on the first and second floor. Delayed egress approved on the first and second floor. There is an approved Hospice Waiver for 10 residents. LPA was accompanied by Executive Director Shetler, during a tour of the facility, which was conducted inside and out and included a sample of resident units, the dining area and recreation rooms, There is a fire signal system in place and the carbon monoxide detectors were operational. The last disaster drill was conducted on November 2023. Exterior and interior passageways were free from obstructions. According to Executive Director Shelter there are no weapons and/or ammunition stored on the premises. Pull cords, sensor alerts with pendants are present in the facility. LPA Rogers observed functionality of signal system. Resident's room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. [Continued on 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

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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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: PLAZA VILLAGE SENIOR LIVING	FACILITY NUMBER: 374602972
	VISIT DATE: 01/22/2024

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[Continued on 809]

Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked room located on the ground floor. Medication room is located on the first floor. The medication carts were locked and stored in the medication room. Medications were labeled and kept in compliance with label instructions. LPA interviews confirmed the Executive Director and staff provide assistance in meeting medical and dental needs.

LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA Rodgers also conducted a review of In-service training procedures. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

No deficiencies were sited at the time of visit; however, technical violation and assistance were issued.

A final exit interview and a copy of this report, Licensee/Appeal Rights - LIC 9058 (rev. 01/16), and LIC9102's were provided to Executive Director Shetler whose signature on this form acknowledges receipt of these documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

LIC809 (FAS) - (06/04)

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