374604154-9-5-2024-08-AS-CLOZ-D8TUJE-20240905153725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604154
Report Date: 09/05/2024
Date Signed: 09/05/2024 03:37:35 PM

Document Has Been Signed on 09/05/2024 03:37 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:	PROVIDE SCH LLC		FACILITY NUMBER:	374604154
ADMINISTRATOR:	SALGADO, MARK		FACILITY TYPE:	735
ADDRESS:	7010 DELOS DR		TELEPHONE:	(619) 773-6043
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92139
CAPACITY:	4	CENSUS: 4	DATE:	09/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Mark Salgado, Licensee		TIME COMPLETED:	03:45 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 Analyst’s (LPA’s) Carmen Lopez and Hanah Rodgers conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA’s Lopez and Rodgers identified themselves, were granted entry by caregiver’s Rowena Bueno and Samantha Salgado. LPA discussed the purpose of the visit with caregivers Bueno and Salgado. Licensee Mark Salgado later arrived and joined the visit. According to the facility’s license, there may be a maximum of four (4) clients all of whom must be ambulatory in at any given time at the facility site. During today’s inspection, the facility’s current census is 4 clients living at the facility. There were 2 clients present at the facility site during the inspection. LPA, accompanied by caregiver Salgado and Licensee Salgado, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities. The facility’s ambient internal temperature was not comfortable upon entrance and measured at 88 degrees Fahrenheit (F) and during the visit measured at 81 degrees F. Hot water temperature at taps accessible to clients were not compliant: kitchen sink measured hot water at 124 degrees F; sink in restroom #1 delivered hot water at 129 degrees F; and sink in restroom #2 delivered hot water at 118.9 degrees F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking, dining equipment and utensils were present, and all safely stored. There were no toxic chemicals or poisons accessible to clients. Medications were properly labeled, as required, and stored in locked areas. The facility-maintained medication logs which LPA’s reviewed. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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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Document Has Been Signed on 09/05/2024 03:37 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: PROVIDE SCH LLC	FACILITY NUMBER: 374604154
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(a)(1)

Fixtures, Furniture, Equipment, and Supplies

(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C). 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 3 out of 6 rooms did not measure the temperatures within the allowed range which posed a potential safety risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Licensee agreed to purchase the thermostats for areas client's associate in and will provide a photo and submit to LPA by POC due date, 09/20/2024.

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). 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 2 out of 3 faucets delivered hot water at taps higher than the allowed temperatres which posed a potential safety risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Licensee will contact a local third party vendor to regulate their heater and take a photo of their hot water temperatures of the kitchen and bathroom #1 and submit to LPA by POC due date, 09/20/2024.

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: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/05/2024 03:37 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: PROVIDE SCH LLC	FACILITY NUMBER: 374604154
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80092.1(l)

General Requirements for Restricted Health Conditions

(l) All training shall be documented in the facility personnel files. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 3 out of 3 staff did not have all training documents located in their personnel file which posed a potential personal rights risk to persons in care.
	POC Due Date: 10/01/2024
	Plan of Correction
1 2 3 4	Licensee will have their staff submit their training documents to them and place it in their file along with any additional training needed, by POC due date, 09/20/2024.

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.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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: PROVIDE SCH LLC	FACILITY NUMBER: 374604154
	VISIT DATE: 09/05/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was present (01) and serviced within the last 12 months. First aid kit was complete and readily accessible.

LPA interviewed staff and clients, and reviewed staff and client records. During today’s visit there were 2 clients on the facility premise. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained most required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

There were deficiencies observed and are being cited during today's annual inspection and may be found on the LIC809-D form of this report.

An exit interview was conducted with Licensee Salgado to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Licensee Salgado to submit a current Personnel Report LIC 500, Emergency Disaster Plan LIC 610-D, and Residential Infection Control Plan LIC 9282 (6/23), to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov. Licensee provided LPA with a current Designation of Administrative Responsibility LIC 308 during the inspection.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

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