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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603760
Report Date: 05/30/2023
Date Signed: 05/30/2023 05:25:43 PM


Document Has Been Signed on 05/30/2023 05:25 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:
05/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 AM
MET WITH:Staff, Betty MangilismanTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 5/30/2023 at 02:15 p.m. LPA was granted entry and met with staff, Betty Mangiliman who was informed of the purpose of the visit. LPA spoke with Administrator Rolando Corpuz over the phone. At the time of the visit there was (3) staff and (5) residents present.

The facility is a one story home with (6) bedrooms and (3) bathrooms with attached garage. No pools or firearms are being kept at the facility. The residents served are elderly ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and client interviews. LPA observed and cited the following:

  • The facility staff and administrator along with LPA observation, found that Resident # (R1) was being held in their bed against their will.


Deficiencies and observations and interviews were documented and will be discussed with the administrator during an informal office visit. The administrator agreed to meet the LPA and their manager on 5/31/2023.

An exit interview was conducted where this report along with deficiency page and appeal rights were reviewed and provided to the staff, Betty Mangilisman.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023
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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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: 05/30/2023
NARRATIVE
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SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/30/2023 05:25 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: 05/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(3)
87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as... interfering with daily living functions...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with R1 who had chairs tied to their bed rails preventing the resident from leaving their bed. LPAobservedthe chair was tied with a belt and staff was standing imeding the resident from leaving her bed. R1 stated they wanted to leave their bed but staff would not let the. Staff and adminsitrator stated the measures where taken to prevent the resident from falling. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2023
Plan of Correction
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LPA had staff remove the belts and chairs immediately and spoke with the administrator who agreed to retrain the staff on the resident personal rights cited above. The administrator agreed to send the LPA the in-service by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023
LIC809 (FAS) - (06/04)
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