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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604036
Report Date: 11/05/2024
Date Signed: 11/05/2024 04:07:02 PM

Document Has Been Signed on 11/05/2024 04:07 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BEST ELMDALE RCFFACILITY NUMBER:
374604036
ADMINISTRATOR/
DIRECTOR:
HILTON. JAZMINFACILITY TYPE:
735
ADDRESS:10330 ELMDALE DRTELEPHONE:
(619) 501-7785
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 4DATE:
11/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Jessica Sosa, Caregiver &
Celina Brown, Administrator
TIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Jessica Sosa, Caregiver to whom LPA discussed the purpose of the visit. Celina Brown Administrator arrived during the visit.

According to the facility’s license, the facility has a maximum capacity of four (4) developmentally disabled adults, four (4) all ambulatory. During today’s inspection, the three (3) were at day programs and one (1) was at the facility.

LPA, accompanied by the Administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was comfortable. Hot water temperature last measured at 114.1 degrees.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BEST ELMDALE RCF
FACILITY NUMBER: 374604036
VISIT DATE: 11/05/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per Administrator Brown, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA conducted interviews. There was 1 client at the facility during the visit. LPA reviewed multiple staff and client records/files. Files reviewed contained required documents. Confidential records were stored in locked areas. Administrator presented proof of current/active business liability insurance and surety bond.

Deficiencies were observed and cited during today's annual inspection.

An exit interview was conducted with Administrator Brown to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/05/2024 04:07 PM - It Cannot Be Edited


Created By: Tiffany Holmes On 11/05/2024 at 12:14 PM
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: BEST ELMDALE RCF

FACILITY NUMBER: 374604036

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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2
3
4
Licensee will email copies of the documents by POC due date of 11/08/2024
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee will email copies of the documents by POC due date of 11/15/2024.
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:Denise Powell
LICENSING EVALUATOR NAME:Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/05/2024 04:07 PM - It Cannot Be Edited


Created By: Tiffany Holmes On 11/05/2024 at 12:14 PM
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: BEST ELMDALE RCF

FACILITY NUMBER: 374604036

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(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 individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interviews and record review, the licensee did not comply with the section cited above in 4 out of 4 client which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2024
Plan of Correction
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Licensee will conduct fire drill today 11/05/2024 and will email/send POC of documented fire drill to CCL by 11/06/2024
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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3
4
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:Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


LIC809 (FAS) - (06/04)
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