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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603760
Report Date: 05/23/2024
Date Signed: 05/23/2024 01:46:45 PM


Document Has Been Signed on 05/23/2024 01:46 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
RIVERSIDE ASC, 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: 3DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rommel Abedoza, Lead CaregiverTIME COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analyst (LPA), Jacqueline Shaw Ross conducted an unannounced visit to the facility for the purpose of a required annual inspection. LPA met with Lead Caregiver, Rommel Abedoza, and explained the nature of the visit and was granted entry into the facility. The facility was inspected inside and out. At the time of the visit, two staff and three clients were present. Staff and client interviews were conducted.
The home is one story and has five bedrooms and four bathrooms. The facility appears clean and free of odors. Staff present have criminal record clearances and are appropriately associated to the facility. Client bedrooms are clean and appropriately furnished. All smoke and carbon monoxide detectors were tested and found operational. Food supplies are sufficient. Emergency food and water was stored in the garage. Hot water was measured in the client's bathroom and deemed safe. LPA observed all toxic chemicals and other hazards secured and inaccessible to clients, except for kitchen knives. LPA observed knives were stored in an unlocked kitchen drawer. Staff immediately placed knives in the appropriate locked drawer. Citation issued. Medications are centrally stored in the kitchen cabinet. LPA observed the following:
Medication was stored in a pill box and not it's original container. Citation issued.
Furniture in the home is in good repair. Outdoor space is free of hazards.
LPA inspected the staff and client records. All staff and client records are up-to -date and contain appropriate documentation such as First Aid Certification and training documents. Current Administrators certification was posted along with all the other documents and signs that require posting.
The facility is not completing emergency drills quarterly. Last drill was conducted one year ago. Citation issued.
An exit interview was conducted and a copy of the report, LIC 9099D, LIC 812, LIC 811 and Appeal Rights was provided to Lead Caregiver Rommel Abedoza.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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 3


Document Has Been Signed on 05/23/2024 01:46 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
RIVERSIDE ASC, 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: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, one of the resident bathrooms did not have a grab bar for the toilet, the licensee did not comply with the section cited above in [3] out of [3] persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2024
Plan of Correction
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Licensee will install a grab bar in the residents bathroom toilet by the POC date of 6/3/2024.
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA observed sharps (knives) were stored in an unlocked drawer in the kitchen, the licensee did not comply with the section cited above in [3] out of [3] objects which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2024
Plan of Correction
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Staff immediatedly removed knives from unlocked kitchen drawer and stored them in a locked kitchen drawer. Licensee will provide a refresher to all staff to remind staff to store sharps in a locked drawer at all times. Licensee will send a letter to the Department indicating their understanding and documentating showing training was completed. Document will contain, date of training, description of training, and signature of all staff who participated in the training by the POC Date of 6/3/2024.
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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/23/2024 01:46 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
RIVERSIDE ASC, 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: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(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 requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, LPA observed medication stored in a pill container and not it's original container. The licensee did not comply with the section cited above in [3] out of [3] persons) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2024
Plan of Correction
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Licensee will conduct a refresher trainer to employees who are authorized to administer medication and provide a copy of completed training that contains name of employee, date of training, and employees signature. This will be provided to the department by the POC date of 6/3/2024.
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 interview and record review, the last drill was conducted over one year ago, the licensee did not comply with the section cited above in [3] out of [3] identifiers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2024
Plan of Correction
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Licensee will conduct a drill and provide proof of drill conducted that contains the date of drill, names of employees who participated in the drill and employees signature of drill completed by the POC date of 6/3/2024.
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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3