374604243-9-30-2024-08-AS-RARZ-D9LSAN-20240930134236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604243
Report Date: 09/30/2024
Date Signed: 09/30/2024 01:42:47 PM

Document Has Been Signed on 09/30/2024 01:42 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:	PLUMOSA PL		FACILITY NUMBER:	374604243
ADMINISTRATOR/ DIRECTOR:	ORR, DIAN		FACILITY TYPE:	735
ADDRESS:	181 PLUMOSA PL		TELEPHONE:	(442) 266-8525
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92058
CAPACITY: 4		CENSUS: 4	DATE:	09/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Licensee Dian Orr		TIME VISIT/ INSPECTION COMPLETED:	01:45 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 (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Licensee Dian Orr. The facility is licensed for a maximum capacity of 4 non-ambulatory clients. During today’s visit, the facility had a census of 4 ambulatory clients, 3 of which were out in the community. The Administrator for the facility is Dian Orr and their certificate was pending. During today’s visit, LPA toured the facility and inspected each room of the facility, including client rooms, bathrooms for client and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA 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 130.9 degrees Fahrenheit in the kitchen sink and 129.2 degrees Fahrenheit in a common bathroom. The Licensee turned down the water heater during the visit. The facility’s internal temperature was measured at 74 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Dian Orr, no firearms or weapons are stored on the premises. LPA also observed locked storage for client medications and client and staff files. Client medications are stored in their original container and labelled. LPA 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 40 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the clients 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. Continued on LIC809-C page…

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024

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: PLUMOSA PL	FACILITY NUMBER: 374604243
	VISIT DATE: 09/30/2024

NARRATIVE

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

The Licensee will submit copies of LIC610D Disaster Plan to the Department within 15 business days.

The following deficiency was cited for hot water and noted on the attached LIC809-D page.

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

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/30/2024 01:42 PM - It Cannot Be Edited

Created By: Rebecca A Ruiz On 09/30/2024 at 01:16 PM

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: PLUMOSA PL	FACILITY NUMBER: 374604243
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2024

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the hot water was measured at 130.9 degrees F in the kitchen sink and 129.2 degrees F in a common bathroom which poses a potential safety risk to 4 of 4 clients in care.
	POC Due Date: 10/31/2024
	Plan of Correction
1 2 3 4	Licensee turned down the hot water heater during the visit. Licensee will put a sign on hot water heater reminding staff not to adjust the temperature and will conduct checks 3 times a week of the hot water temperature on a temperature log. Licensee submit the hot water log to the Department by POC due date of 10/31/2024.

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

LICENSING EVALUATOR NAME:

Rebecca A Ruiz

LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024

LIC809 (FAS) - (06/04)

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