374603419-12-28-2023-18-AS-JGEE-CYY3LA-20231228172025

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603419
Report Date: 12/28/2023
Date Signed: 12/28/2023 05:20:30 PM

Document Has Been Signed on 12/28/2023 05:20 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CASA DEL SOL RTF		FACILITY NUMBER:	374603419
ADMINISTRATOR:	MANUEL VASQUEZ		FACILITY TYPE:	735
ADDRESS:	1561 E MISSION RD		TELEPHONE:	(442) 444-8156
CITY:	FALLBROOK	STATE: CA	ZIP CODE:	92028
CAPACITY: 4		CENSUS: 2	DATE:	12/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Manuel Vazquez, Licensee/Administrator		TIME COMPLETED:	05:00 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	On 12/28/23 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection as well as health and safety check. LPA with with Licensee/Administrator Manuel Vazquez. Below is an account of LPAs observations of the conducted inspection. At the time of the visit there was two (2) clients and one (1) staff present. The facility was observed to be within the licensed capacity (4). The facility is a single story home with (4) resident bedrooms, (2) bathrooms, garage, living room, and backyard. The exterior was observed to be clutter free. LPA observed for there to be ample activities both inside and outside to provide entertainment for the clients in care. The facility previously used video surveillance, as LPA observed for there to be 3 cameras in the common areas of the facility. Per the Licensee Mr. Vazquez the cameras are not being utilized as there was a request for outside parties to access them and posed a breach in confidentiality. The cameras are still hanging. LPA discussed if things were to change the following was needed: an addendum to the facility's plan of operation is required, updated facility sketch and acknowledgement that the clients and their responsible parties were informed. Interior: the resident bedrooms were observed to have the required furniture mattresses, night stands, storage space, and sufficient lighting. The bathroom appliances were observed to be operable, however LPA observed a leak underneath the bathroom sink. LPA observed a bowl underneath the pipe, that was used to catch the water. The bowl was full and was overflowing with water was leaking out of the cabinet and onto the bathroom floor. There is a second bathroom available for the clients to use and the hot water measured to be within regulatory limits of 105 degrees Fahrenheit. The Licensee contacted the facility's maintenance staff to come and repair the leaking pipe. Proof of the repairs will be submitted, as soon as they are completed.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CASA DEL SOL RTF	FACILITY NUMBER: 374603419
	VISIT DATE: 12/28/2023

NARRATIVE

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The carbon monoxide and smoke detectors were observed to be operable. There are three (3) fully charged fire extinguishers. The facility is out of compliance with conducting the disaster drills. The last disaster drill was conducted on May 5, 2023. A citation will be issued, and can be found on the attached 809D. The facility was stocked with a 2-day supply of perishable and 7-day supply of non-perishable food items.

The medications are locked inside a medication cart. The facility had a designated area for resident files and staff files. All staff present have a criminal record clearance on file and are associated to the facility. The facility was observed to have all the required postings such as PUB475, LIC610E, the disaster plan will be updated to reflect current staffing. However there was not a current administrator's certificate as it has not been issued due there being a discrepancy with the course numbers from the vendor where Mr. Vazquez completed the required training.

The facility was also equipped with a complete first aid kit as well as the first aid manual. There was shaded area with seating. The facility is in compliance as the business' governing body is active and functioning.

An exit interview was conducted and a copy of the report, 809D and appeal rights were provided to Manuel Vazquez, Licensee.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/28/2023 05:20 PM - It Cannot Be Edited

Created By: Javina George On 12/28/2023 at 04:40 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CASA DEL SOL RTF	FACILITY NUMBER: 374603419
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 1 times which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	The licensee agrees to conduct a disaster drill. Proof of completed drill is to be submitted to the department by 5pm on the due date indicated.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jazmond D Harris

LICENSING EVALUATOR NAME:

Javina George

LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC809 (FAS) - (06/04)

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