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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604213
Report Date: 09/16/2024
Date Signed: 09/16/2024 11:55:42 AM

Document Has Been Signed on 09/16/2024 11:55 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SACRED HEART HOME CAREFACILITY NUMBER:
374604213
ADMINISTRATOR/
DIRECTOR:		DOMINGO P IMSON JRFACILITY TYPE:
735
ADDRESS:829 BEGONIA STREETTELEPHONE:
(760) 975-3849
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 4CENSUS: 4DATE:
09/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:06 AM
MET WITH:Ludivina Frogoso, Caregiver TIME VISIT/
INSPECTION COMPLETED:
12:05 PM
NARRATIVE
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On 09/16/24 at 9:06am Licensing Program Analysts (LPAs) Debbie Palacios and Javina George made an unannounced visit to the facility to conduct an annual inspection/1 year required visit. LPAs were greeted and granted entry by Caregivers Jamie and Ludivina Frogoso, where LPAs explained the purpose of today's visit. At the time of the visit there was (2) staff and (2) clients present. A tour was conducted of the interior and exterior of the facility.

The facility was observed to be clean, and the passageways were free from obstruction. The emergency disaster drills are being conducted every other month, the last drill was conducted on 09/12/24. The combined smoke and carbon monoxide detectors were tested and found to be operable. The medications were observed to be locked and inaccessible to clients in care, and are to be given to physician instructions as evidenced by the Medication Authorization Record (MAR).

The chemicals and sharps were observed to be locked and inaccessible to clients in care. The facility has (2) fully charged fire extinguishers that are fully charged with the tag in tact. The are no known guns on the premises in addition to no pools or bodies of water. The hot water was tested and measured and found to be hot measuring at 127.2 degrees Fahrenheit

The facility food supply met the requirements of a 2 day supply of perishable and a 7 day supply of nonperishable food items.

A records review of both staff and client files was conducted. Client files were observed to have the required documentation such as admissions agreement, medical assessment, Individual Program Plan (IPP). Staff present at the facility were observed to have obtained criminal record clearance, and to be associated the facility. In addition to having valid CPR certification, and Direct Support Professional training.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SACRED HEART HOME CARE
FACILITY NUMBER: 374604213
VISIT DATE: 09/16/2024
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Based on today's inspection citations were on the attached 809D issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 6).

The Licensee will submit the following to the department by 5pm on Wednesday 09/18/24.

-Updated LIC 610D emergency disaster plan
- Hang a copy of CCL complaint poster
-Conduct an audit to ensure that all employees have a file at the facility

An exit interview was conducted and a copy of this report, appeal rights, LIC 9098-Proof of Corrections form was provided to Ludivina Frogoso, Caregiver.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2024 11:55 AM - It Cannot Be Edited


Created By: Javina George On 09/16/2024 at 11:37 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SACRED HEART HOME CARE
FACILITY NUMBER: 374604213

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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. (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
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 times as the hot water temperature measured to be 127.2 degrees Fahrenheit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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The licensee agrees to adjust the water temperature, and take and log the temeprature for 1 week. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024


LIC809 (FAS) - (06/04)
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