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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603041
Report Date: 01/09/2024
Date Signed: 01/09/2024 02:06:35 PM

Document Has Been Signed on 01/09/2024 02:06 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:BANDOLA RESIDENTIAL CAREFACILITY NUMBER:
374603041
ADMINISTRATOR:DOMDOM, NOVELITA V.FACILITY TYPE:
735
ADDRESS:4096 VIA DE LA BANDOLATELEPHONE:
(619) 690-1290
CITY:SAN YSIDROSTATE: CAZIP CODE:
92173
CAPACITY: 6CENSUS: 3DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Novelita Domdom, LicenseeTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by Licensee Novelita Domdom. LPA discussed the purpose of the visit with Licensee Domdom.

According to the facility’s license, there may be a maximum of six (6) clients all of whom may be non-ambulatory in at any given time at the facility site. During today’s inspection, the facility’s current census is 3 clients living at the facility. There were no clients present at the facility site during the inspection.

LPA, accompanied by Licensee Dondom, toured the interior and exterior areas of the facility, and inspected each room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, 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, laundry, visitation, meetings, and activities.

The facility’s ambient internal temperature was at 68 degrees Fahrenheit. Hot water temperature at taps accessible to clients were as follows: kitchen sink was at 124.9 degrees F; sink in restroom #1 delivered hot water at 126.7 degrees F; sink in restroom #2 delivered hot water at 135.3 degrees F; sink in restroom #3 delivered hot water at 134.4 degrees F; and sink in restroom #4 delivered hot water at 133.2 degrees F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present, and all safely stored. There were no toxic chemicals/poisons accessible to clients. Medications were properly labeled, as required, and stored in locked cabinet. LPA inspected the medication area and found that medications were properly labeled and stored in a locked cabinet. The facility maintained medication logs which LPA reviewed.

[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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: BANDOLA RESIDENTIAL CARE
FACILITY NUMBER: 374603041
VISIT DATE: 01/09/2024
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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present (03) and serviced within the last 12 months. First aid kit were complete and readily accessible.

LPA was unable to interview staff or clients, but reviewed staff and client records. During today’s visit there were no clients on the facility premise. LPAs inspection did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

Deficiencies observed and cited during today's annual inspection may be found on the LIC809-D page at the end of this report.

An exit interview was conducted, and a POC was jointly developed with Licensee Novelita Domdom to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Licensee Domdom to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, and Emergency Disaster Plan LIC 610-D, to the licensing office within 10 business days. The Residential Infection Control Plan LIC9282 (6/23) was submitted to the San Diego Regional Office. Forms are available at www.ccld.ca.gov.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/09/2024 02:06 PM - It Cannot Be Edited


Created By: Carmen Lopez On 01/09/2024 at 01:30 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: BANDOLA RESIDENTIAL CARE
FACILITY NUMBER: 374603041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 5 out of 5 faucets were over the allowed 120 degrees temperature which poses an immediate safety risk to 3 of 3 persons in care.
POC Due Date: 01/24/2024
Plan of Correction
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Licensee has lowered the hot water temperature and will monitor the temperature of the facility faucets. Licensee will email LPA once the temperatures have been lowered to the allowed temperature and send LPA photo's of the temperatures at each faucet for a total of 5 faucet temperature photos by POC due date, 1/24/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Denise Powell
LICENSING EVALUATOR NAME:Carmen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/09/2024 02:06 PM - It Cannot Be Edited


Created By: Carmen Lopez On 01/09/2024 at 01:30 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: BANDOLA RESIDENTIAL CARE
FACILITY NUMBER: 374603041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(a)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the facility's ambiant temperature was lower than the allotted temperature of 68 degrees F, which posed a potential personal rights risk to 3 of 3 persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Licensee has individual heaters for the clients but will ensure that the facility heater is fixed and will contact their contractor to fix by POC due date, 1/31/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Denise Powell
LICENSING EVALUATOR NAME:Carmen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
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