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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603744
Report Date: 05/15/2024
Date Signed: 05/15/2024 02:32:34 PM


Document Has Been Signed on 05/15/2024 02:32 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:SKYVIEW GARDENSFACILITY NUMBER:
374603744
ADMINISTRATOR:WERY, TERRY ANNFACILITY TYPE:
740
ADDRESS:14215 MIDLAND ROADTELEPHONE:
(858) 335-0916
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:15CENSUS: 11DATE:
05/15/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Manager Mirtha OropezaTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Continuation Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Manager Mirtha Oropeza. The facility was licensed for a capacity of fifteen (15) non-ambulatory residents, of which thirteen (13) may be bedridden. A hospice waiver for five (5) was also approved. During the visit the facility had a census of eleven (11).

During the inspection the LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected resident bedrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. No pools, nor bodies of water bodies of water were observed on the premises. Per staff, no firearms or ammunition were kept at the facility.

The LPA conducted interviews and reviewed staff and resident records. Deficiencies were noted in an LIC 809D and a Plan of Correction (POC) was jointly formulated with Manger Oropeza.

An exit interview was conducted with Manager Oropeza, to whom a copy of this report, LIC 811, and the Licensee/Appeal Rights (LIC9058), were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
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 05/15/2024 02:32 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: SKYVIEW GARDENS
FACILITY NUMBER: 374603744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of records and interview, the licensee did not comply with the section cited above in 2 out of 11 (R1 and R2) persons in care, which poses/posed a potential health, safety or personal rights risk to persons in care 2 of 11 residents in care..
POC Due Date: 06/05/2024
Plan of Correction
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Manager agreed to obatin physician's reports for R1 and R1 and send them to the LPA, by 6/5/24.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of records and interview, the licensee did not comply with the section cited and did not ensure emegency drills were conducted quarterly, which posed a potential health, safety or personal rights risk to 11 of 11 persons in care.
POC Due Date: 06/05/2024
Plan of Correction
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Manager agreed to conduct an emegency drill for all shifts, and send documentation to the LPA, by 6/5/24.
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: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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