374603760-6-14-2023-18-AS-JARA-CST3G6-20230614181349

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603760
Report Date: 06/14/2023
Date Signed: 06/14/2023 06:13:54 PM

Document Has Been Signed on 06/14/2023 06:13 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 WEST		FACILITY NUMBER:	374603760
ADMINISTRATOR:	CORPUZ, ROLANDO		FACILITY TYPE:	740
ADDRESS:	1681 DAYBREAK PLACE		TELEPHONE:	(760) 737-6799
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92027
CAPACITY:	6	CENSUS:	DATE:	06/14/2023
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Administrato, Rolando "Bobby" Corpuz		TIME COMPLETED:	06:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct a plan of correction visit. Deficiency were cited on 5/30/2023 during a required annual inspection and 5/31/2023 during an informal office meeting. The LPA met with administrator, Rolando "Bobby" Copruz who was informed of the purpose of the visit. During the visit a health and safety check was conducted on the facility residents. During the time of the visit LPA conducted a walk through of the facility interior and exterior. LPA observed the residents, the food supply, and utilities. The following deficiency was corrected during today's POC visit: Deficiency cited under Title 22 Regulation 87465(h)(2) Incidental Medical and Dental Care. POC 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 6/6/2023. Deficiency has been cleared as during this visit as the LPA observed medications in locked hallway closet and received photos of this by the POC due date. Clearance letter was given to administrator during the time of the visit. Deficiency cited under Title 22 Regulation 87303(a) Training Requirements If Advertising Dementia Special Care, Programming And/Or Environments . The POC made with the administrator was to hold an in-service with staff and themselves in attendance and send proof of this to the LPA by the POC due date 6/6/2023. The topics shall include: dementia care and fall risk prevention. On today's visit LPA asked for staff training and was show training material staff received and completed. LPA asked staff if they had received fall risk and dementia care training who stated they had received it. LPA received staff sign in sheet by POC due date. Clearance letter was given to administrator during the time of the visit.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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 2

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
	VISIT DATE: 06/14/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Deficiency cited under Title 22 Regulation 87456(i) Incidental Medical and Dental Care. The POC made with the administrator was to dispose of the expired medication and submit proof of removal of the medication from the facility along with medication destruction record by the POC due date 6/6/2023. On today's visit LPA observed and took photos of facility built-in fridge which no longer contained expired medication. LPA received copies of medication destruction record by POC due date. Clearance letter was given to administrator during the time of the visit.

Deficiency cited under Title 22 Regulation 87303(a) Maintenance and Operation. The POC made with the administrator was to have the built in refrigerator removed, and to submit proof to LPA by the POC due date of 6/6/2023. LPA received proof of this by the POC due date. Clearance letter was given to administrator during the time of the visit.

The following deficiencies were not corrected by the POC due date nor at the time of the visit. Civil Penalties are being assessed and will continue to accrue until correction has been submitted:
Deficiency cited under Title 22 Regulation 87465(h)(5) Incidental Medical and Dental Care. The POC made with the administrator was 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 6/6/2023. On today's visit LPA spoke with administrator and staff who stated that they had not trained staff on medication administration. During the visit LPA found that the pill boxes had been removed from the facility and been sent photos that pill boxes had been removed. Civil penalties are being assessed for the dates of 6/7/2023 to 6/14/2023 in the amount of $100 per day for 8 days. Civil penalties will continue to accrue at the rate of $100 corrections are made and sent to LPA.

Deficiency cited under Title 22 Regulation 87405(a) Administrator- Qualifications and Duties. The POC made with the administrator was to spend 20 hours a week at the facility and to oversee Daybreak Villa East and West and remove themselves as administrator from the other (3) facilities. Proof of removal from facilities as administrator, LIC500 showing the 20 hours allotted per week. This was due by POC date 6/6/2023. On today's visit LPA spoke to administrator who stated they had sent the LPA LIC308 to designate their house managers in their place for other (3) facilities but had not disassociated themselves. POC documented has still not been received. Civil penalties are being assessed for the dates of 6/7/2023 to 6/14/2023 in the amount of $100 per day for 8 days. Civil penalties will continue to accrue at the rate of $100 corrections are made and sent to LPA.

An exit interview was conducted with administrator, Rolando Corpuz where this report and civil penalties were reviewed and provided.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2