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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604090
Report Date: 08/18/2026
Date Signed: 08/19/2026 08:06:17 AM

Document Has Been Signed on 08/19/2026 08:06 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ST ANDREWS SUITESFACILITY NUMBER:
374604090
ADMINISTRATOR/
DIRECTOR:		SHERWIN, MARCOSFACILITY TYPE:
740
ADDRESS:17023 ST ANDREWS DRTELEPHONE:
(520) 548-0138
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 6DATE:
08/18/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:23 AM
MET WITH:Administrator Sherwin MarcosTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified herself to, and discussed the purpose of the visit to Administrator Sherwin Marcos.

Community Care Licensing received an Incident Report on 8/17/26 in which it was reported that on 8/14/26, Resident #1 (R1) had a fall while left alone on the toilet when receiving toileting assistance from two staff. [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] Per the report, R1 sustained a broken femur that required surgery. As of today, R1 has not returned to the facility from the hospital.

During today's visit, LPA reviewed facility records and interviewed staff. Per records reviewed, R1 requires assistance with toileting, including equipment or assistance of another person. Interviews with staff admitted leaving R1 on the toilet alone and reported it was "the routine everyday" for R1. LPA consulted with Administrator regarding R1's care and supervision needs and the facility's plan moving forward.

A deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). The citation is issued for facility neglect in not following R1's assessment outlining a need for toileting assistance. Civil Penalties are under review by the Department and may be assessed at a later date.

An exit interview was conducted with Administrator Sherwin Marcos to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided at the conclusion of the visit. Signature below confirms receipt of these documents.
Simon Jacob
Angelica Boyles
DATE: 08/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/19/2026 08:06 AM - It Cannot Be Edited


Created By: Angelica Boyles On 08/18/2026 at 12:01 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: ST ANDREWS SUITES
FACILITY NUMBER: 374604090

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/28/2026
Section Cited
CCR
87468.2(a)(8)

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87468.2: In addition to the rights listed in Section 87468.1 [...] residents...shall have all of the following personal rights: (8)To be free from neglect [...]
This requirement is not met as evidenced by:
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R1 has not yet returned to the facility. Licensee will conduct an in-service training with staff on care plans and toileting assistance. Licensee will submit this to LPA by POC due date.
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Based on record review and interviews, the Licensee did not ensure R1 was receiving toileting assistance as indicated, resulting in injury. This posed an immediate health and safety risk to 1 out 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2026


LIC809 (FAS) - (06/04)
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