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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603665
Report Date: 01/28/2022
Date Signed: 01/28/2022 03:04:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:DEVON PLACE HOME CAREFACILITY NUMBER:
374603665
ADMINISTRATOR:MARK LOOFACILITY TYPE:
740
ADDRESS:1814 DEVON PLACETELEPHONE:
(760) 941-1818
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 5DATE:
01/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sherryl Rafols, Caregiver/AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a case management. LPA Lopez identified herself and was granted entry by Sherryl Rafols, Caregiver/Administrator. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Administrator Rafols.

During today's visit, during a complaint investigation, LPA Lopez spoke with staff and residents, toured the facility, and requested and obtained relevant documents. LPA Lopez verified that the facility did not submit self-reported incident reports for Resident 1 (R1) and Resident 2 (R2) (see LIC811, Confidential Names List). Based on information obtained, deficiencies are being cited during today’s visit regarding reporting requirements. LPA Lopez provided additional guidance on reporting requirements.

An exit interview was conducted with Administrator Rafols, and a copy of this report, LIC811 form and Licensee Appeal Rights (LIC9058) was emailed to Administrator Rafols and Licensee Mark Loo. LPA requested for a confirmation of receipt via electronic response to confirm the receipt of these documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/04/2022
Section Cited

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Reporting Requirements (a)(1)(B) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... Any serious injury ... This requirement was not met as evidence by:
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Based on the information received during interviews and resident records obtained. This poses a potential health and safety risk to 5 of 5 residents 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: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2022
LIC809 (FAS) - (06/04)
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