374603699-10-24-2022-18-AS-CNWE-CKHSF3-20221024134940

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603699
Report Date: 10/24/2022
Date Signed: 10/24/2022 01:49:44 PM

Document Has Been Signed on 10/24/2022 01:49 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SAPPHIRE LAKE SAN MARCOS		FACILITY NUMBER:	374603699
ADMINISTRATOR:	MATIC, VICTORIA		FACILITY TYPE:	740
ADDRESS:	839 LA TIERRA DRIVE		TELEPHONE:	(760) 471-1157
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92078
CAPACITY:	6	CENSUS: 6	DATE:	10/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:56 PM
MET WITH:	Victoria Matic, Administrator Ali Naghibi, Licensee		TIME COMPLETED:	01:55 PM

NARRATIVE

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Licensing Program Analyst (LPA), Chinwe Nwogene made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Administrator, Victoria Matic who was informed of the purpose of the visit. Victoria called Licensee representative, Ali Naghibi who arrived at the facility shortly after. At the time of visit there was 2 staff and 6 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility inside and out with Victoria and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer and paper towels) in all restrooms. The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be any event of COVID-19 related illnesses. The facility has a designated infection control lead. The facility also cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed PPE supplies.

During the tour of the kitchen LPA observed a knife and scissors on top of the microwave on the kitchen counter. Victoria immediately locked up the knife and made the knife inaccessible to residents. LPA was informed by administrator, Victoria that facility has dementia residents. Deficiency will be cited.

Therefore, based on the observations made during today’s visit, one #1 deficiency was cited per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted, and this reported was provided along with appeal rights to Ali Naghibi.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

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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Document Has Been Signed on 10/24/2022 01:49 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SAPPHIRE LAKE SAN MARCOS	FACILITY NUMBER: 374603699
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above by leaving a knife on the kitchen counter accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2022
	Plan of Correction
1 2 3 4	Administrator, Victoria Matic immediately locked up the knife and made it inaccessible for resident in care. Licensee, Ali Naghibi stated a letter of understanding of nthe regulation cited above will be provided to LPA by the POC due date 10/25/2022.

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: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

LIC809 (FAS) - (06/04)

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