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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603228
Report Date: 03/22/2024
Date Signed: 03/22/2024 04:39:11 PM

Document Has Been Signed on 03/22/2024 04:39 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:RB SENIOR RESIDENCES IIFACILITY NUMBER:
374603228
ADMINISTRATOR:COOK, CHERRYFACILITY TYPE:
740
ADDRESS:15158 JENELL STREETTELEPHONE:
(858) 883-2180
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 4DATE:
03/22/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caregiver Rhoda Amago and Onsite Manager Anafe RiveraTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Manager (LPM) Lizzette Tellez and Licensing Program Analysts (LPAs) Juliana Barfield and Adrian Mangina conducted an unannounced continuation visit for a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to and discussed the purpose of the visit with Casey Villas. Administrator Kathleen Marquez arrived during the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) residents, all of whom may be non-ambulatory. One resident may be bedridden in bedroom #6. During today’s inspection, there were a total of four (4) residents in care. This facility does not feature delayed egress doors.

LPM and LPAs, accompanied by Ms. Marquez, toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction. Client bedrooms contained the required furnishings. 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 client activities.
Hot water temperature at taps accessible to clients were all compliant. There was at least 2 days supply of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no sharp objects, fireplaces, or open-faced heaters observed available to clients. Medications were labeled, as required, and stored in locked areas.

During the inspection LPA observed two bedridden residents (R1-R2) residing in rooms not cleared for bedridden residents. The facility has fire clearance for one bedridden resident. Disinfectants were observed in an unsecured cabinet accessible to residents in care. Exterior exit gates and inside exit door were observed to be locked with padlocks and key operated deadbolt. Tour of the facility bathroom revealed shower mats were missing from two of three bathrooms, and a toilet seat was missing from one toilet. During facility record review, the administrator was unable to produce documentation or date of the last drill. During resident room tour, an oxygen in use sign was not posted in the appropriate area. Additionally, the facility houses residents with major neurocognitive disorder who present a risk of wandering and had disabled the auditory devices.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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Document Has Been Signed on 03/22/2024 04:39 PM - It Cannot Be Edited


Created By: Juliana Barfield On 03/22/2024 at 03:09 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: RB SENIOR RESIDENCES II
FACILITY NUMBER: 374603228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in two out of four persons (R1-R2) which posed an immediate safety risk to persons in care. An immediate civil penalty in the amount of $500 was assessed during today's visit.
POC Due Date: 03/25/2024
Plan of Correction
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Licensee agreed to relocate R1 to the approved bedridden room, and initiate eviction proceedings for R2. Proof of relocation and a copy of the eviction notice to be provided to CCL by POC due date.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 as disinfectants were observed in an unlocked cabinet, which posed an immediate safety risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Licensee agreed to secure the disinfectants in a locked cabinet. Photo proof due to CCL by POC due date.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Juliana Barfield
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


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Page: 2 of 7
Document Has Been Signed on 03/22/2024 04:39 PM - It Cannot Be Edited


Created By: Juliana Barfield On 03/22/2024 at 03:09 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: RB SENIOR RESIDENCES II
FACILITY NUMBER: 374603228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(l)(2)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

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 when both outside exterior doors were observed with a padlock and inside door was observed with key operated deadbolt, which posed an immediate safety risk to persons in care. An immediate civil penalty in the amount of $500 was assessed during today's visit.
POC Due Date: 03/25/2024
Plan of Correction
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Licensee removed the outside padiock and agreed to replace the key operated deadbolt. Photo proof to be provided to CCL by POC due date.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Juliana Barfield
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


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Document Has Been Signed on 03/22/2024 04:39 PM - It Cannot Be Edited


Created By: Juliana Barfield On 03/22/2024 at 03:09 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: RB SENIOR RESIDENCES II
FACILITY NUMBER: 374603228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

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 two out of three bathrooms which posed a potential safety risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Licensee installed non-skid mats in all bathrooms. Deficiency cleared during the visit.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

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 one of three toilets which did not have a toilet seat, which poses a potential safety risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee agreed to install a toilet seat riser and provide photo proof to CCL by POC due date.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Juliana Barfield
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


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Document Has Been Signed on 03/22/2024 04:39 PM - It Cannot Be Edited


Created By: Juliana Barfield On 03/22/2024 at 03:09 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: RB SENIOR RESIDENCES II
FACILITY NUMBER: 374603228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 when a drill was not conducted in the prior quarter, which posed a potential safety risk to persons in care.
POC Due Date: 04/22/2024
Plan of Correction
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Licensee agreed to conduct a drill and provide proof of training to CCL by POC due date.
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

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 one of six resident rooms, which poses a potential safety risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Licensee placed a sign on the resident room during the visit. Deficiency cleared.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Juliana Barfield
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 03/22/2024 04:39 PM - It Cannot Be Edited


Created By: Juliana Barfield On 03/22/2024 at 03:09 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: RB SENIOR RESIDENCES II
FACILITY NUMBER: 374603228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

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 when all auditory devices were disabled on all exit doors, which posed a potential safety risk to persons in care.
POC Due Date: 04/22/2024
Plan of Correction
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Licensee turned on the auditory devices during the visit. Licensee agreed to provide staff with training regarding care of persons with Dementia. Proof of training to be provided to CCL by POC due date.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Juliana Barfield
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


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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: RB SENIOR RESIDENCES II
FACILITY NUMBER: 374603228
VISIT DATE: 03/22/2024
NARRATIVE
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Deficiencies were observed in the areas evaluated and are cited in accordance with the California Code of Regulations, Title 22. This report was discussed with Caregiver, Casey Villas. A copy of this report was provided to them at the conclusion of the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
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