374603345-9-24-2024-08-AS-RARZ-D9EQNH-20240924121909

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603345
Report Date: 09/24/2024
Date Signed: 09/24/2024 12:19:22 PM

Document Has Been Signed on 09/24/2024 12:19 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:	JOSTER VILLA		FACILITY NUMBER:	374603345
ADMINISTRATOR:	HERMINIA SANTOS		FACILITY TYPE:	740
ADDRESS:	10864 WORTHING AVENUE		TELEPHONE:	(858) 860-5135
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92126
CAPACITY:	6	CENSUS: 6	DATE:	09/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Administrator Herminia Santos		TIME COMPLETED:	12:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Hannah Rodgers and Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPAs were greeted by, identified themselves to, and explained the purpose of the visit with DSP Urbanobann Pacioles. Administrator Herminia Santos arrived during the visit. The facility is licensed for a maximum capacity of 6 non-ambulatory residents. The facility has a waiver for 2 hospice residents. During today’s visit, the facility had a census of 6 residents of which none were hospice. Administrator certificate was valid and current. During today’s visit, LPAs toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPAs did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was in compliance for 4 out 4 sinks. The facility’s internal temperature was measured at 75 degrees Fahrenheit. LPAs observed locked storage for all hazardous and toxic chemicals and were stored separately from food supplies. According to Hermina Santos, no firearms or weapons are stored on the premises. LPAs also observed locked storage for resident medications. Resident's medications are stored in their original container and labelled. LPAs observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator and freezer were in compliance. LPAs observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. Continued on LIC809-C page...

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

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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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: JOSTER VILLA	FACILITY NUMBER: 374603345
	VISIT DATE: 09/24/2024

NARRATIVE

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LPAs reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property and cash resources, and personal rights. LPAs reviewed residents’ personal and incidental money and ledger with the Administrator and did not discover any inconsistencies. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPAs spoke with staff present at the facility during the time of the inspection and those interviews did not reveal any licensing regulatory concerns. Residents were either out in the community or declined to speak to LPAs during the time of the visit.

The Administrator will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days.

No deficiencies were cited on today’s date. An exit interview was conducted with Administrator Herminia Santos, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC809 (FAS) - (06/04)

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