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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603306
Report Date: 06/17/2024
Date Signed: 06/17/2024 02:53:43 PM

Document Has Been Signed on 06/17/2024 02:53 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:REBECCA'S RETREATFACILITY NUMBER:
374603306
ADMINISTRATOR/
DIRECTOR:		REBECCA CHONGFACILITY TYPE:
775
ADDRESS:9307 TROPICO DRIVETELEPHONE:
(619) 206-0590
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY: 14CENSUS: 14DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Karen Graves, Program CoordinatorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced Required 1 year Annual Visit. LPA was allowed entry by Karen Graves, Program Facilitator. LPA identified herself and disclosed the purpose of the visit with the Program Facilitator.

Physical Environment:  The facility was clean, maintained, and free from any safety hazards. Adequate lighting and ventilation were observed in all areas of the facility. All necessary safety equipment, such as fire extinguishers and emergency exits, were not present at the time of the visit or expired. The facility's outdoor spaces were properly maintained and accessible to residents.

Staffing and Training:  The facility had a sufficient number of qualified staff members to meet the needs of the residents.  The staff member was observed to be professional, courteous, and knowledgeable in their respective roles.  All staff members had completed the required training and certifications per the licensing regulations.  Staffing schedules were posted and adhered to, ensuring adequate coverage.

Continued 809C
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 06/17/2024 02:53 PM - It Cannot Be Edited


Created By: Renita Hall On 06/17/2024 at 01:26 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: REBECCA'S RETREAT
FACILITY NUMBER: 374603306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82075(b)(5)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, program staff designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

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 2 out of 14 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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Develop a Medication Administration Record (MAR) by June 24, 2024.
Type A
Section Cited
CCR
82075(b)(6)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, program staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met:

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 2 out of 14 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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Develop a Medication Administration Record (MAR) by June 24, 2024.
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:Renita Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/17/2024 02:53 PM - It Cannot Be Edited


Created By: Renita Hall On 06/17/2024 at 01:28 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: REBECCA'S RETREAT
FACILITY NUMBER: 374603306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82075(b)(6)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, program staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) The date and time the PRN medication was taken, the dosage taken, and the client's response, shall be documented and maintained in the client's record.

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 2 out of 14 (persons) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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Develop a Medication Administration Record
Type A
Section Cited
CCR
82075(l)(1)
Health-Related Services
(l) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2024
Plan of Correction
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Lock all medication centrally stored by June 18, 2024
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:Renita Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2024 02:53 PM - It Cannot Be Edited


Created By: Renita Hall On 06/17/2024 at 01:29 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: REBECCA'S RETREAT
FACILITY NUMBER: 374603306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82075(l)(3)
Health-Related Services
(l) The following requirements shall apply to medications which are centrally stored: (3) All medications shall be labeled and maintained in compliance with label instructions and state and federal laws.

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 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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Participants must bring in the original labeled medications to facility.
Type A
Section Cited
CCR
82075(l)(4)
Health-Related Services
(l) The following requirements shall apply to medications which are centrally stored: (4) No person other than the dispensing pharmacist shall alter a prescription label.

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 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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All medications given to participants must be in the original dispensing containers.
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:Renita Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2024 02:53 PM - It Cannot Be Edited


Created By: Renita Hall On 06/17/2024 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: REBECCA'S RETREAT
FACILITY NUMBER: 374603306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82075(l)(5)
Health-Related Services
(l) The following requirements shall apply to medications which are centrally stored: (5) Each client's medication shall be stored in its originally received container.

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 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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Have all medications in the original received contatiner by June 24, 2024.
Type A
Section Cited
CCR
82075(m)
Health-Related Services
(m) Prescription medications which are not taken with the client upon termination of services, or which are not to be retained shall be destroyed by the administrator, or a designated substitute, and one other adult who is not a client.

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 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
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:Renita Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024


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: REBECCA'S RETREAT
FACILITY NUMBER: 374603306
VISIT DATE: 06/17/2024
NARRATIVE
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Resident Care and Services:  Residents' care plans were reviewed and up-to-date.  Medication administration was observed to violate policies and procedures. Residents' nutritional needs were met, and the meals provided were nutritious and well-balanced. Recreational activities and social engagement opportunities were available to residents regularly.

Health and Safety:  Regular health assessments and monitoring of residents' well-being were conducted by qualified healthcare professionals.  Infection control measures were in place and followed by staff members. The facility established protocols for emergencies and evacuation plans were not readily available.

An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058) was provided to Karen Graves, Program Facilitator. Her signature on this form confirms receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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