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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603760
Report Date: 05/31/2023
Date Signed: 05/31/2023 04:31:35 PM


Document Has Been Signed on 05/31/2023 04:31 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 WESTFACILITY NUMBER:
374603760
ADMINISTRATOR:CORPUZ, ROLANDOFACILITY TYPE:
740
ADDRESS:1681 DAYBREAK PLACETELEPHONE:
(760) 737-6799
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 5DATE:
05/31/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Rolando 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 the facility, and the use of restraints.
  • Fall prevention training for administrator and staff
  • Dementia care training for administrator and staff
  • Unlocked medication observed in facility common areas
  • Removal of inoperable facility refrigerator
  • Proper disposal of expired medications
  • Transferring of medication to other containers
  • Not giving medication as prescribed to (R1) and Resident #2 (R2)
  • 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)
Page: 1 of 5


Document Has Been Signed on 05/31/2023 04:31 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 WEST
FACILITY NUMBER: 374603760

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2023
Section Cited
CCR
87465(h)(2)

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(h) The following requirements shall apply to medications... (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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The licensee agreed to place all medications in a safe and locked area in the facility and send the LPA proof of this by the POC due date.
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This requirment was not met as evidenced by: LPA observed unlocked medications that were being kept in (2) facility refrigerators in facility kitchen and living room. This poses an immediate health, saftey or personal rights risk to residents.
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Type A
06/06/2023
Section Cited
CCR87465(h)(5)

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(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirment was not met as evidenced by:
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The licensee agreed to retrain their staff on medication administration and send proof to the LPA of staff in service to discontinue use of weekly pill boxes by the POC due date.
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LPA observed all (5) residents had their medication transferred into weekly pill boxes from their original containers. This is an immediate personal rights, health or saftey risk to resident sin 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: 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)
Page: 2 of 5


Document Has Been Signed on 05/31/2023 04:31 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 WEST
FACILITY NUMBER: 374603760

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2023
Section Cited
CCR
87465

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(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirment was not met as ebidenced by:
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The licensee agreed to retrain staff on the medication administration. Staff in-service will be sent to the LPA by the POC due date.
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The LPA reviewed medication for R1 and R2 and found that the medication was required everyday per hospice paper work. Staff stated, and MARS logged showed resident was receiving medication as needed. This is an immediate health, saftey or personal rights risks to residents.
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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)
Page: 3 of 5


Document Has Been Signed on 05/31/2023 04:31 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 WEST
FACILITY NUMBER: 374603760

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
87303(a)

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(a) The facility shall be...in good repair at all times...provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirment was not met as evidenced by:
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The adminsitrator agreed to have the built in refrigerator removed, and to submit proof to LPA by the POC due date.
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Based on LPA observation and administrator statements, the facility had a built-in refrigerator which was inoperable in facility kitchen, that was being used to store unlocked medications and documents. This poses a potential health, saftey, or personal rifghts risk to residents in care.
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Type B
06/06/2023
Section Cited
CCR87456(i)

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(i) Prescription medications which are...which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years... This requirment was not met as evidenced by:
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The licensee agreed to dispose of the expired medication and submit proof of removal of the medication from the facility along with medication destrction record by the POC due date.
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The LPA observed medication in the facility that was unlocked and expired. This medication had not been disposed of by the facility and poses a potential health, saftey or personla rights risk to resident 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: 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)
Page: 4 of 5


Document Has Been Signed on 05/31/2023 04:31 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 WEST
FACILITY NUMBER: 374603760

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
87707(a)

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(a) Licensees who advertise, promote, or otherwise hold themselves out as providing special care...for residents with dementia...shall ensure that all direct care staff...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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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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