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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603338
Report Date: 10/30/2024
Date Signed: 10/31/2024 08:19:13 AM

Document Has Been Signed on 10/31/2024 08:19 AM - 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:EASY LIVING @ MIRA MESAFACILITY NUMBER:
374603338
ADMINISTRATOR/
DIRECTOR:
CALCETA, MYRNAFACILITY TYPE:
740
ADDRESS:10136 ZAPATA AVENUETELEPHONE:
(858) 566-7233
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Administrator, Oliver CalcetaTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility and conducted the visit with Administrator, Oliver Calceta. The facility is licensed for six (6) Non-Ambulatory Elderly residents; One (1) of whom may bedridden in bedroom #3 only.

LPA, accompanied by Administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, 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 resident activities. Hot water temperature at taps accessible to residents measured at 111 F.. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. However, the medications did not appear accurate due to the facility not using a Medication Administration Record or calendar count on bubble packs. Also, the facility's Centrally Stored Medication Destruction Record was not accurate due to not having any start dates of the medication to ensure an accurate audit of medications.

No pools or bodies of water were observed on the premises. Per the Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files did not contain required documents. Staff did not have a required health screening or TB test results on file. Resident #1 (R1) had a change in condition, the facility did not comply with regulations. Multiple residents did not have required documentation, to include TB test results. Confidential records were stored in locked areas.

Deficiencies were observed or cited during today's annual inspection. Advisory Notes were also issued. An exit interview was conducted with the Administrator to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
Robyn ClarkTELEPHONE: (619) 767-2312
Natasha PersaudTELEPHONE: (619) 301-3594
DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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 10/31/2024 08:19 AM - 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: EASY LIVING @ MIRA MESA

FACILITY NUMBER: 374603338

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 5 [S1-S2] staff by not having health screening and TB test results on file which poses a potential health and safety risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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Administrator stated he will be obtain current health screenings to include TB test results and submit proof 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: Robyn ClarkTELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/31/2024 08:19 AM - 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: EASY LIVING @ MIRA MESA

FACILITY NUMBER: 374603338

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review, the licensee did not comply with the section cited above in 1 out of 3 [R1] residents when R1 had a change in condition and the facility did not obtain an updated physician's report or conduct a current reappraisal, which poses a potential health and safety risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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Administrator stated he will obtain a current Physician's Report and assess R1 to provide an updated reappraisal and submit proof 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: Robyn ClarkTELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/31/2024 08:19 AM - 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: EASY LIVING @ MIRA MESA

FACILITY NUMBER: 374603338

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and record review, the licensee did not comply with the section cited above in 1 out of 3 [R1-R3] residents, by not punching the bubble packs accurately, and/or documenting accurately to prove medications are given as prescribed, as there are no start dates for medications, which poses a potential health and safety risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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Administrator stated he will provide medication training regarding accuracy with pill count by indicating the start date on the bubble pack/pill bottle and provide proof of training by POC due date. Administrator also stated he will document the Centrally Stored Medication Destruction Record to ensure accuracy moving forward, as the new cycle medications were already delivered and start date was not 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: Robyn ClarkTELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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