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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603565
Report Date: 09/27/2024
Date Signed: 09/27/2024 03:37:59 PM


Document Has Been Signed on 09/27/2024 03:37 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:LA VIDA REALFACILITY NUMBER:
374603565
ADMINISTRATOR:GARCIA, KIMBERLYFACILITY TYPE:
740
ADDRESS:11588 VIA RANCHO SAN DIEGOTELEPHONE:
(619) 660-5778
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:177CENSUS: 120DATE:
09/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Director Kimberly Garcia TIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit. LPA met with Executive Director Kimberly Garcia, and discussed the purpose of the visit. Today's visit is in response to a self reported incident from the facility dated 9/20/2024.

On 9/23/2024, CCLD received an SOC341 regarding Resident 1 (R1). The date of incident was 9/19/24, regarding alleged personal rights violation. On today's date, LPA conducted interviews and reviewed facility records.

According to SOC341, R1 reported to Staff 2 (S2) that on the night of 9/19/2024, Staff 1 (S1) refused to assist resident in requesting medication for pain. Interview with R1 corroborated that S1 refused to assist and proceeded to take away R1's call button while using inappropriate language towards R1. Interview with multiple outside sources revealed that there have been previous instance of S1 being rude with other residents and taking R1's cellular phone away. Outside source confirmed that prior instances had been reported to previous Executive Director. Based on R1's Physician Report, R1 is diagnosed with a major neurocognitive disorder but is capable of communicating need and does not have any inappropriate or aggressive behaviors. Interview with current Executive Director revealed that S1 has since been separated from facility.

At this time a preponderance of evidence exists to show S1 violated R1's personal rights. A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages).

An exit interview was conducted with Executive Director, to whom a copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
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 09/27/2024 03:37 PM - 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: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2024
Section Cited
CCR
87468.1(a)(1)

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87468.1(a)Residents.... shall have... the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement was not met as evidence in that:
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Licensee agrees to provide resident personal rights specifically to be accorded dignity in their personal relationships with staff by plan of correction date to LPA.
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Based on interviews the licensee did not accord residents with dignity in 3 of 120 #persons in care (R1, R2, R3) which posed a Personal Rights risk to persons in care.

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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: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
LIC809 (FAS) - (06/04)
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