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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603814
Report Date: 05/26/2022
Date Signed: 05/26/2022 11:37:10 AM

Document Has Been Signed on 05/26/2022 11:37 AM - 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SOLARIS 30FACILITY NUMBER:
374603814
ADMINISTRATOR:ARCA, LUCIAFACILITY TYPE:
740
ADDRESS:14530 GARDEN RDTELEPHONE:
(858) 883-2680
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 6DATE:
05/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Jubal Gonzales, CaregiverTIME COMPLETED:
11:58 AM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Miller conducted a case management visit to cite a deficiency identified during a separate Required 1-Year Annual Visit for a separate facility. The facility is in close proximity to other facilities on a large cul-de-sac. LPA knocked on the front door to inquire if the facility was the one due for the annual inspection. LPA heard someone inside yell, "Come in." When LPA entered, she saw three residents sitting in the living room. Staff 1 (S1) entered the room then without a mask. LPA identifying herself and disclosed the purpose of the visit. LPA then asked if Heidi had a mask. LPA observed that S1 checked her pockets and did not pull out a mask. S1 stepped into the garage where PPE was stored to find a mask. LPA inquired what facility she was in and where she could find the correct facility to do her annual inspection.

A second caregiver (S2) entered the room without a mask holding a plate with debris on it. LPA introduced herself and asked where his mask was. Jubal took his mask from his pocket and explained that he had just finished eating.

A deficiency was cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations (see LIC809-D). An exit interview was conducted with caregiver to whom a copy of this report and the Licensee appeal Rights (LIC9058) were provided.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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 05/26/2022 11:37 AM - It Cannot Be Edited


Created By: Esther Miller On 05/26/2022 at 11:12 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SOLARIS 30
FACILITY NUMBER: 374603814

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2022
Section Cited
CCR
87468.1(a)(2)

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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: (2) To be accorded
safe, healthful…accommodations.” This
requirement was not met, as evidenced by:
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Caregiver suggested an internal in-service training on PIN 21-38-ASC. Administrator will submit the training-sign in sheet to LPA by the POC due date.
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Based on LPA observations, licensee did not accord residents specific required safe and healthful accommodations. This posed a potential health risk to 6 of 6 residents 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:Denise Powell
LICENSING EVALUATOR NAME:Esther Miller
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
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