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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603759
Report Date: 05/31/2023
Date Signed: 05/31/2023 04:32:53 PM


Document Has Been Signed on 05/31/2023 04:32 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:DAYBREAK VILLA EASTFACILITY NUMBER:
374603759
ADMINISTRATOR:CORPUZ, ROLANDOFACILITY TYPE:
740
ADDRESS:1682 DAYBREAK PLACETELEPHONE:
(760) 781-1079
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 6DATE:
05/31/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Roland CorpuzTIME COMPLETED:
10:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola and Licensing Program Manger (LPM) Joel Esquivel conducted an informal office meeting virtually with Administrator, Roland Corpuz on 5/31/2023 at 9:00 a.m. The meeting was accorded to discuss the following points:
  • Deficiency cited by LPA Arreola on 5/30/2023 concerning Resident #1 (R1) at facility Daybreak Villa East 374603760, and the use of restraints.
  • Fall prevention training for administrator and staff
  • Dementia care training for administrator and staff
  • Administrator increasing hours present at the facility to 20 hours per week.


These items were discussed with the administrator, where they agreed to have the items corrected by June 6,2023 and present corrections to LPA. Citations were recorded on LIC809-D page along with plans of correction.

The administrator agreed to contact the licensee, as both the LPA and LPM were unable to gain contact for the informal meeting. The administrator agreed to inform the LPA by June 1, 2023 availability for June 2,2023.

An exit interview was conducted where plans of correction for these issues were reviewed and discussed with Administrator, Roland Corpuz. The report was sent to Rolando Corpuz via email for signature.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023
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 05/31/2023 04:32 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: DAYBREAK VILLA EAST
FACILITY NUMBER: 374603759

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2023
Section Cited
CCR
97707(a)

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(a) Licensees who...hold themselves out as providing special care...for residents with dementia...shall ensure that all direct care staff... who provide care to residents with dementia, meet...training requirements This requirment was not met as evidenced by:
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The licensee agreed to hold an inservice with staff and themselves in attendance and send proof of this to the LPA by the POC due date. The topics shall include: dementia care and fall risk prevention.
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Based on record review and interview with administrator, the staff at the facility have not received dementia care training as outlined in the facility's dementia care plan. This poses a potential personal, health or safety risk.
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Type B
06/06/2023
Section Cited
CCR87405(a)

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(a) ...The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours...The Department may require that the administrator devote additional hours in the facility to fulfill his...responsibilities...This requirment was not met as evidenced by:
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The administrator agreed to spend 20 hours a week at the facility and to oversee Daybreak Villa East and West and remove themselves as adminsitrator from the other (3) facilities. Proof of removal from facilities as administrator, LIC500 showing the 20 hours alotted per week,
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During the informal meeting, the Administrator stated they oversaw (5) facilities and that they were unware fo the extent of the use of the retraints with R1, and medication that was stored unlocked. This poses a potential health, saftey, personal rights risk to residents.
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and signed statement of understanding of the regualtion cited by the administrator must be submitted by the POC due date.
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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023
LIC809 (FAS) - (06/04)
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