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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603236
Report Date: 04/15/2024
Date Signed: 04/15/2024 04:17:08 PM


Document Has Been Signed on 04/15/2024 04:17 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:ROXIES ELDERLY HOMES IFACILITY NUMBER:
374603236
ADMINISTRATOR:TERESITA ROXASFACILITY TYPE:
740
ADDRESS:290 HOLIDAY WAYTELEPHONE:
(442) 266-2938
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 5DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee Teresita "Roxie" RoxasTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Licensee Teresita "Roxie" Roxas.

The facility is licensed for a maximum capacity of 6 non-ambulatory residents. The facility has a waiver for 4 hospice residents. During today’s visit, the facility had a census of 5 non-ambulatory residents, 4 of which were receiving hospice services. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Teresita "Roxie" Roxas and their certificate was valid and current.

During today's visit, LPA briefly toured the facility and observed residents in care, and reviewed facility records. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed.

During today's visit, LPA observed Person 1 (P1) present at the facility without a background clearance. [Licensee was provided with an LIC811 Confidential Names List to identify P1]. Per Licensee, P1 has been present at the facility for more than 5 calendar days. The following deficiency for uncleared individuals present at the facility is being cited per California Code of Regulations Title 22 and noted on the attached LIC809-D page. Additionally, a civil penalty for uncleared individuals is being cited for a total of $500 and noted on the attached LIC421BG form.

An exit interview was conducted with Licensee "Roxie" Roxas, whose signature below confirms receipt of a copy of this report, the LIC421BG, LIC811, and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
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 04/15/2024 04:17 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: ROXIES ELDERLY HOMES I
FACILITY NUMBER: 374603236

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
(e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility:

(1) Obtain a California clearance or a criminal record exemption as required by the Department

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the licensee did not comply with the section cited above as Person 1 (P1) was not background cleared and was present at the facility for more than 5 days. This poses an immediate safety risk to 5 of 5 persons in care.
POC Due Date: 04/15/2024
Plan of Correction
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LPA observed P1 leave the facility prior to the end of the visit. Licensee will have P1 fingerprinted and will submit paperwork to the Department to have P1 criminal background cleared and associated to the facility prior to P1 returning to the facility.
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: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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