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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603220
Report Date: 02/12/2024
Date Signed: 02/12/2024 12:32:35 PM


Document Has Been Signed on 02/12/2024 12:32 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:EDWARD JAMES RETIREMENT HOME, LLCFACILITY NUMBER:
374603220
ADMINISTRATOR:SONGCO, ARCELI B.FACILITY TYPE:
740
ADDRESS:1132 W VIA RANCHO PKWYTELEPHONE:
(760) 294-8791
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:6CENSUS: 2DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Arceli Songco, AdministratorTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit/annual inspection. LPA was greeted and granted entry by caregiver Daniel Tallant. LPA explained the purpose of the visit. The Administrator arrived shortly after, LPAs arrival. There was one (1) staff and two (2) residents present at the time of LPAs visit.

LPA conducted a tour of the interior and exterior of the facility. The following observations were made:
The facility is a single story home with four (4) resident bedrooms and two (2) staff bedrooms, and three (3) bathrooms. There is a kitchen, family room, office and backyard with a pool (drained) within a locked chain link fence with a shed that is used for storage and a bathhouse, that is not being utilized.

LPA observed the required postings, and for the facility to have a sufficient food supply, of a 2 day supply of perishable and a 7 day supply of non perishable food items. The facility had an adequate amount of paper supplies and locked EPA approved cleaners. The facility had activities to promote socialization. The smoke and carbon monoxide detectors were tested and observed to be operable. The medications and sharp objects are locked and are inaccessible to residents in care. Resident #1 (R1) has an order for their medications to be crushed. There are no guns or ammunition stored on grounds.

LPA observed the following deficiencies were observed:
-There were no emergency disaster drill logs available to review confirming that the drills are being conducted on a quarterly basis as required
-LPA observed for the facility to be using video surveillance inside of the resident bedrooms
A citation will be issued on the attached 809D, in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8)
An exit interview was conducted and a copy of this report, and appeal rights were reviewed and provided to Arceli Songco, Administrator.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
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 02/12/2024 12:32 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: EDWARD JAMES RETIREMENT HOME, LLC
FACILITY NUMBER: 374603220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 1 times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
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The licensee agrees to conduct an emergency disaster drill, no later than tomorrow 2/13/24. Proof is to be submitted to the department by 5pm on the due date indicated.
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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/12/2024 12:32 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: EDWARD JAMES RETIREMENT HOME, LLC
FACILITY NUMBER: 374603220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above in 2 out of 2 times which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2024
Plan of Correction
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The licensee agrees to remove the cameras from inside the resident bedrooms. Should the licensee continue to use cameras. The licensee agrees to complete an addendum to the plan of operation to include the use of cameras in the common areas. The licensee agrees to have the resident/responsible party sign a consent regarding camera use. Proof is to be submitted to the department by 5pm on the due date indicated.
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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
LIC809 (FAS) - (06/04)
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