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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603354
Report Date: 08/11/2022
Date Signed: 08/11/2022 11:41:01 AM

Document Has Been Signed on 08/11/2022 11:41 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MAISY PLACEFACILITY NUMBER:
374603354
ADMINISTRATOR:MELANIE CUARESMAFACILITY TYPE:
735
ADDRESS:101 N UPAS STTELEPHONE:
(760) 738-6237
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 6CENSUS: 2DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Kevin Ramirez, Direct Care staffTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA), Chinwe Nwogene made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by caregiver, Juanario Payumo who was informed of the purpose of the visit. Juanario called Licensee, Melanie Cuaresma who sent the Direct Care staff, Kevin Ramirez to the facility. At the time of visit there was 1 staff and 2 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility inside and out with Juanario and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer and paper towels) in all restrooms. LPA did not observe an pool or bodies of water within the premises. LPA was informed that no weapons or ammunition is maintained at the home. No annual Fees due.

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be any event of COVID-19 related illnesses. The facility has a designated infection control lead. The facility also cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed PPE supplies.

Also, during the tour LPA observed Cleaning solutions and medications not locked. Citation will be issued.

Therefore, based on the observations made during today’s visit, the following deficiencies will be cited per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted, and this reported was provided along with appeal rights to Kevin Ramirez.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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 3
Document Has Been Signed on 08/11/2022 11:41 AM - It Cannot Be Edited


Created By: Chinwe Nwogene On 08/11/2022 at 11:08 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MAISY PLACE
FACILITY NUMBER: 374603354

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) 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 LPA 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: 08/22/2022
Plan of Correction
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Although Caregiver Juanario immediately locked the medication, Kevin stated a written statement of understanding of the regulation cited above will be submitted to LPA by POC due date 8/22/2022
Type A
Section Cited
CCR
80087(g)
(g) Disinfectants, Cleaning Solutions, Poisons, Firearms and other items that coild pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA 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: 08/22/2022
Plan of Correction
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Although Caregiver Juanario Immediately locked the cleaning solutions, Kevin stated a written statement of understanding of the regulation cited above will be submitted to LPA by POC due date 8/22/2022.
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:Deborah Mullen
LICENSING EVALUATOR NAME:Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022


LIC809 (FAS) - (06/04)
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