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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604057
Report Date: 06/10/2022
Date Signed: 06/14/2022 02:22:58 PM


Document Has Been Signed on 06/14/2022 02:22 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:PLATEAU VILLAGE MEMORY CAREFACILITY NUMBER:
374604057
ADMINISTRATOR:DIVINA NUNEZFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY:56CENSUS: 36DATE:
06/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Executive Director, Divinia NunezTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management visit. LPA met with Executive Director, Divinia Nunez and we discussed the purpose of the visit.

On 08/24/2021, the Department substantiated a complaint alleging neglect/lack of supervision of Resident #1 (R1). A citation under Title 22 Regulations 87465(g) was issued. On today’s date, the Department is issuing a $500.00 civil penalty under HSC 1569.49(c)(1), for a violation that the Department determined resulted in an injury of R1.

An exit interview was conducted and a copy of this report, LIC 421IM – Civil Penalty Assessment Form, and Licensee Rights (LIC 9058 01/16) were provided to Divinia Nunez whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1].

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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 06/14/2022 02:22 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: PLATEAU VILLAGE MEMORY CARE
FACILITY NUMBER: 374604057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited

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Civil penalties; regulations setting forth appeal procedures for deficiencies. The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for...the department determines resulted in the injury or illness of a resident.
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This requirement is not met as evidenced by:
Based on interviews and review of record, the licensee did not contact 911 or obtain emergency medical services for 1 out of 26 residents. This posed an immediate health and safety risk to residents in care.
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The Department is issuing a $500.00 civil penalty under HSC 1569.49(c)(1), for a violation that the Department determined resulted in an injury of R1.

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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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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