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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604085
Report Date: 05/26/2021
Date Signed: 05/26/2021 04:55:46 PM

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:SANTA MARTHA RESIDENTIAL VIFACILITY NUMBER:
374604085
ADMINISTRATOR:ALCARAZ, FLORA KELLYFACILITY TYPE:
740
ADDRESS:3810 GOVERNOR DRTELEPHONE:
(858) 583-6431
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY:6CENSUS: 5DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Pillar Moreno, Caregiver
& Flora Moreno, Administrator		TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Manager (LPA) Licensing Program Analyst Tiffany Holmes conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with Pilar Moreno and we discussed the purpose of the visit. The Licensee, Flora Moreno, Administrator arrived during the visit. All staff present have a current criminal record clearance.

LPA conducted a tour of the facility, both inside and outside and observed the residents in care. In accordance with the Department’s Infection Control, LPA provided technical assistance, evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment.

Deficiencies were observed and cited on this date and are on the 809 D.

The Licensee was provided a copy of their appeal rights (LIC9058 01/16). An exit interview was conducted and a copy of this report was emailed to the Licensee with an electronic read receipt as confirmation of documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SANTA MARTHA RESIDENTIAL VI
FACILITY NUMBER: 374604085
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(1)
Personal Rights of residents in all facilities:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee failed to ensure that staff speak to residents with respect. LPA heard a staff state "Callate la boca" in Spanish while on the porch standing at the front door waiting to enter. This means shut your mouth in English, which poses a potential safety risk of residents in care.
POC Due Date: 06/01/2021
Plan of Correction
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Licensee will train staff on personal rights and treating residents with respect. Licensee will send in Staff sign in sheet and documents regarding the training to CCL.
POC will be submitted to licensing no later than POC date of 06/01/2021.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accomodation and Services:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee failed to ensure that the furniture in the facility is not moved to obstruct passage ways so residents can walk or roll through the facility, which poses a potential safety risk of residents in care.
POC Due Date: 06/01/2021
Plan of Correction
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Staff immediately put the furniture back in its rightful place and Licensee will train staff on not obstructing passageways. Licensee will send in Staff sign in sheet and documents regarding the training to CCL. POC will be submitted to licensing no later than POC date of 06/01/2021.
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: Simon JacobTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021
LIC809 (FAS) - (06/04)
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