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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603671
Report Date: 05/10/2023
Date Signed: 05/10/2023 03:17:21 PM


Document Has Been Signed on 05/10/2023 03:17 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:SAPPHIRE ESCONDIDO ESTATESFACILITY NUMBER:
374603671
ADMINISTRATOR:ALI NAGHIBIFACILITY TYPE:
740
ADDRESS:262 SILVERCREEK GLENTELEPHONE:
(760) 291-1202
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:6CENSUS: 6DATE:
05/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Imelda "Amy" Santos, Caregiver
Liz Rivera, Administrator		TIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Tricia Danielson Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit to address a deficiency observed during the investigation of complaint control number 18-AS-20230502105304.
During review of facility records on 5/10/2023, it was discovered that Resident #1 (R1) has a sole primary diagnosis of paranoid schizophrenia. R1's ongoing behavior is not compatible with the other residents of the facility and has upset the resident group in it's entirety. On 4/28/2023, R1 unjustifiably physically assaulted Resident #2 (R2), who is bedridden and non-verbal, with a hairbrush.

Therefore, based on LPA's observations, the following deficiencies were cited per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list and Appeal Rights.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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 05/10/2023 03:17 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: SAPPHIRE ESCONDIDO ESTATES
FACILITY NUMBER: 374603671

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2023
Section Cited

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Acceptance and Retention Limitations-(c) No resident shall be accepted or retained if any of the following apply:(3) The resident's primary need for care and supervision results from either: (A) An ongoing behavior, caused by a mental disorder, that would upset the general resident group. This requirement was not met as evidenced by:
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The licensee will work with R1's conservator to find alternative appropriate placement at another licensed facility. Proof of R1's placement elsewhere to be submitted to LPA by POC due date.
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The licensee did not follow acceptance and retention limitations. Based on review of R1's physician's report, R1 is soley diagnosed with paranoid schizophrenia and upset the resident group when they unjustifably assaulted R2 with a hairbrush. This poses a potential health, safety, and personal rights risk to 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: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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