374603565-1-2-2024-08-AS-AROS-CZ4NMZ-20240102093559

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603565
Report Date: 12/29/2023
Date Signed: 01/02/2024 09:36:32 AM

Document Has Been Signed on 01/02/2024 09:36 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:	LA VIDA REAL		FACILITY NUMBER:	374603565
ADMINISTRATOR:	DAVID ARMOUR		FACILITY TYPE:	740
ADDRESS:	11588 VIA RANCHO SAN DIEGO		TELEPHONE:	(619) 660-5778
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92019
CAPACITY:	177	CENSUS: 144	DATE:	12/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Director of Assisted Living Perla Provencal		TIME COMPLETED:	03:15 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) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Director of Assisted Living Perla Provencal, after identifying herself and stating the purpose of the inspection. This facility serves one hundred and Seventy Seven (177) non- ambulatory elderly residents 60 and above; thirty (30) of whom may be bedridden. Hospice waiver approved for 24. A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. There is a three-story complex with memory care on the first and second floor. PPE supplies are onsite. Passageways were free from obstructions. Facility does feature a locked perimeter on the first and second floor. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

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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Document Has Been Signed on 01/02/2024 09:36 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: LA VIDA REAL	FACILITY NUMBER: 374603565
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 5 of 8 resident rooms, which poses a potentia safety risk to persons in care.
	POC Due Date: 01/29/2024
	Plan of Correction
1 2 3 4	Director David Armour agreed to perform a room inventory and purchase non-skid mats for the residents rooms. Director agreed to then submit photographic evidence to LPA by the POC due date.

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: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: LA VIDA REAL	FACILITY NUMBER: 374603565
	VISIT DATE: 12/29/2023

NARRATIVE

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Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room not assessable to residents. Centrally stored medications were properly stored and locked in cabinets. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions.

Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures and made recommendations. LPA conducted a review of In-service training procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

Based on LPA observation of resident’s rooms, licensee did not provide non- skid mats or strips in some room showers, which posed a potential health and personal rights risk to persons in care. A technical violation was also issued at today’s visit.

Deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with Director David Armour and Director of Assisted Living Perla Provencal. An exit interview was conducted with Director of Assisted Living Provencal to whom copies of this report, the LIC 809-D page, the LIC 9102TV, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of this visit..

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC809 (FAS) - (06/04)

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