374604200-11-22-2023-08-AS-NPED-CXTM97-20231122082415

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604200
Report Date: 11/21/2023
Date Signed: 11/22/2023 08:25:01 AM

Document Has Been Signed on 11/22/2023 08:25 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	NEW WORLD RCFE		FACILITY NUMBER:	374604200
ADMINISTRATOR:	CARMEN CAMPAS		FACILITY TYPE:	740
ADDRESS:	14125 TARZANA ROAD		TELEPHONE:	(858) 748-2888
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	6	CENSUS: 6	DATE:	11/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Administrator, Carmen Campas		TIME COMPLETED:	06:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by staff, Wendy Pedraza. The Administrator, Carmen Campas arrived during the visit.

LPA, accompanied by the administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean and sanitary. The main bathroom has a drawer missing exposing parts of the drawer that could cause injury. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, 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 resident activities. Hot water temperature at taps accessible to residents measured at 67 F.. There is a freezer located in the garage that has mold and excessive ice build up.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were cleaning supplies under the kitchen sink cabinet made accessible to residents. Medications were labeled, as required, but not locked, the medication cart lock was broken and sitting in the common area, allowing access to all medications.

No pools or bodies of water were observed on the premises. Per the administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed multiple staff and residents. LPA reviewed multiple staff and resident records/files. The interviews did not raise any significant licensing concerns. Staff records reflected they do not have the required training. Confidential records were stored in a locked areas. Continued on an LIC 809C.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

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: NEW WORLD RCFE	FACILITY NUMBER: 374604200
	VISIT DATE: 11/21/2023

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Technical Assistance were provided for the broken/missing cabinet drawer, water temperature, freezer in the garage, and fire extinguisher's dial is pointing to the red area, instead of the green area that indicates it's ready for use.

Deficiencies were observed and cited during today's annual inspection. An exit interview was conducted with Administrator, Carmen Campas to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/22/2023 08:25 AM - 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NEW WORLD RCFE	FACILITY NUMBER: 374604200
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

The following requirements shall apply to medications which are centrally stored: 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 6 out of 6 [R1-R6] which poses an immediate health and safety risk to persons in care.
	POC Due Date: 11/22/2023
	Plan of Correction
1 2 3 4	The administrator moved the medication cart to a locked room, removing the immediate threat. The administrator stated they will purchase a new lock for the medication cabinet and attend medication training. Proof of training will be submitted within 2 weeks.

Type A

Section Cited

CCR

87705(f)(2)

The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above in 6 out of 6 [R1-R6] persons which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/22/2023
	Plan of Correction
1 2 3 4	The administrator had staff lock all of the cleaning supplies in the garage, removing the immediate threat. In addition, the administator stated staff will attend dementia safety training to include ensuring all cleaning supplies are inaccessible and provide proof of training within 2 weeks.

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/22/2023 08:25 AM - 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NEW WORLD RCFE	FACILITY NUMBER: 374604200
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 6 [S1-S2] staff, which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/19/2023
	Plan of Correction
1 2 3 4	The administrator stated she will have all staff attend required trainings and provide proof of training by POC due date.

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC809 (FAS) - (06/04)

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