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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604147
Report Date: 10/25/2021
Date Signed: 10/25/2021 01:21:30 PM

Document Has Been Signed on 10/25/2021 01:21 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:VILLA LA CRESTA HOMEFACILITY NUMBER:
374604147
ADMINISTRATOR:MANAIG, LORELIEFACILITY TYPE:
735
ADDRESS:2375 LA CRESTA RDTELEPHONE:
(619) 456-2788
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY: 6CENSUS: 4DATE:
10/25/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Lorelie ManaigTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA), Alexandre, Vo, made an announced visit to conduct a pre-licensing inspection for a Change of Capacity application from six (6) to four (4). LPA was allowed entry into the facility by Licensees, Lorelie and June Manaig, after identifying himself and stating the purpose of the inspection. The facility is requesting to serve four (4) adults with developmental disabilities, aged 18-59, all of whom must be ambulatory. Facility's fire clearance was granted and received at the San Diego office on October 21, 2021. This is a four bedroom and three bathroom house. Two bedrooms and two bathrooms are designated for clients' use. There is no secured perimeter.

LPA was accompanied by the Licensee during the tour of the facility, which was conducted inside and out. LPA ensured facility reflects the sketch provided. Facility has one or more operating smoke alarms. Fire extinguishers were examined and determined to be in compliance. All inside and outside passageways are clear of obstructions. There are no pools or bodies of water observed. According to the Licensee, no guns and/or ammunition are stored on the premises.

Facility has a two-day supply of perishable, and a seven-day supply of non-perishable food items. Clients have clean linen in good repair and sufficient hygiene products to meet their needs. Clients’ bathrooms were equipped with toilets, sinks, and showers in operating and sanitary conditions. Showers were equipped with non-slip material or rugs. Hot water temperature at faucets for clients’ use were measured at 106 degrees F in bathroom #1 and 111 degress F in bathroom #2.

There is a locked storage area for medication. Chemicals and poisons will be stored in a locked area, separate from food supplies. There is a locked storage area for the confidential keeping of staff and client files. The first aid kit and manuals were checked.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alexandre Vo
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2021
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: VILLA LA CRESTA HOME
FACILITY NUMBER: 374604147
VISIT DATE: 10/25/2021
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Based on today’s inspection, a deficiency was cited and listed on the LIC809D. A plan of correction was developed with the Licensee. LPA observed evidence of pests in the dining room and in the food pantry. Facility sketch is to be updated with video surveillance locations and security bars to indicate quick release in bedrooms #2 and #3. Technical Assistance was provided to obtain the Long-Term Care Ombudsman Poster and the poster is to be placed in a prominent area. Application will be forwarded to management pending final review.

An exit interview was conducted and a copy of this report and Licensee/Appeals Rights (9058 01/16) were provided to the Licensee by electronic mail. An e-mail confirmation was requested upon receipt of the documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alexandre Vo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/25/2021 01:21 PM - It Cannot Be Edited


Created By: Alexandre Vo On 10/25/2021 at 10:51 AM
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: VILLA LA CRESTA HOME
FACILITY NUMBER: 374604147

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2021
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by:
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Licensee agreed to submit the initial invoice or treatment inspection by Plan of Correction date. Licensee agreed to keep quarterly pest inspection report available for review.
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Based on observations, the licensee did not provide a clean or sanitary environment due to evidence of mouse droppings, ants, and rodent eaten food in the dining room and food pantry. This poses a potential health risk to four of the four clients 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.
SUPERVISOR'S NAME:Simon Jacob
LICENSING EVALUATOR NAME:Alexandre Vo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2021


LIC809 (FAS) - (06/04)
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