374604116-11-18-2024-08-AS-RARZ-DB5TP2-20241118135336

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604116
Report Date: 11/18/2024
Date Signed: 11/18/2024 01:53:45 PM

Document Has Been Signed on 11/18/2024 01:53 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:	JULIA'S COTTAGE AT THE HILLS		FACILITY NUMBER:	374604116
ADMINISTRATOR/ DIRECTOR:	GOKER, JULIA		FACILITY TYPE:	740
ADDRESS:	2150 STEIGER LN		TELEPHONE:	(858) 735-4054
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92056
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Administrator Julia Goker		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Rebecca Ruiz and Arian Golbakhsh conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPAs were greeted by, identified themselves to, and explained the purpose of the visit with Caregiver Edna Sto Domingo. Administrator Julia Goker arrived during the visit. The facility is licensed for a maximum capacity of 6 non-ambulatory residents, 1 of which may be bedridden in room #4. The facility has a waiver for 6 hospice residents. During today’s visit, the facility had a census of 6 residents, 1 ambulatory and 5 non-ambulatory. The Administrator for the facility is Julia Goker and their certificate was valid and current. During today’s visit, LPAs toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPAs did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 107.4 degrees Fahrenheit in the kitchen sink and 110.5 degrees Fahrenheit in a private resident bathroom. The facility’s internal temperature was measured at 74 degrees Fahrenheit. LPAs observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Julia Goker, no firearms or weapons are stored on the premises. LPAs also observed locked storage for resident and staff files. LPAs observed four resident medication bottles placed upon a desk at the main entry and were not secured. Administrator Julia Goker removed the bottles and secured them in the medication cabinet during the visit. Resident medications are stored in their original container and labelled. LPAs observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 38 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. Continued on LIC809-C page…

Jennifer Lott	TELEPHONE: (619) 346-3976
Rebecca A Ruiz	TELEPHONE: (619) 318-7620
	DATE: 11/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

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: JULIA'S COTTAGE AT THE HILLS	FACILITY NUMBER: 374604116
	VISIT DATE: 11/18/2024

NARRATIVE

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LPAs observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate.

LPAs reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPAs spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

The Administrator will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days.

The following deficiency was cited for unsecured medications and noted on the attached LIC809-D page. Additionally, a technical violation regarding physician orders was issued and noted on an LIC9102TV form.

An exit interview was conducted with Administrator Julia Goker, whose signature below confirms receipt of a copy of this report, the LIC9102TV, and the Licensee Appeal Rights (LIC9058 3/22).

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/18/2024 01:53 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: JULIA'S COTTAGE AT THE HILLS	FACILITY NUMBER: 374604116
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that four medication bottles were not secured in the locked medication cabinet, which poses a potential safety risk to 6 of 6 residents in care.
	POC Due Date: 12/02/2024
	Plan of Correction
1 2 3 4	Administrator relocated medication bottles to the secured medication cabinet during the visit. Administrator will be conducting in-service training with staff regarding accepting medications and will submit a staff sign-in sheet to the Department by POC due date of 12/2/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 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.

Jennifer Lott	TELEPHONE: (619) 346-3976
Rebecca A Ruiz	TELEPHONE: (619) 318-7620
	DATE: 11/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

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