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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604245
Report Date: 11/09/2022
Date Signed: 11/09/2022 03:24:17 PM

Document Has Been Signed on 11/09/2022 03:24 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:CHLOE'S HOMEFACILITY NUMBER:
374604245
ADMINISTRATOR:ENGAY, ERWINFACILITY TYPE:
735
ADDRESS:228 CARTER STREETTELEPHONE:
(619) 995-8874
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY: 4CENSUS: 3DATE:
11/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Licensee Erwin Engay TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vicky Williamson conducted a case management visit to cite for deficiencies observed during a visit to the facility on 10/10/22; also, failure to report an incident to Community Care Licensing regarding Client 2(C2) causing damage to a neighbor’s property, date unknown. LPA was met and granted entry into the facility by Licensee Erwin Engay to whom the purpose of the visit was discussed. LPA and licensee toured the facility and discussed the changes to the physical plant observed by LPA on 10/10/22. On 10/10/22, LPA observed that the patio area outside of the family room of the facility had been closed in serving as a closed in patio area with two door that exit out to the backyard area. The patio has been closed in with a wood panel around the entire patio approximately 4 ft tall with lattice around the top area of the patio except around both of the half doors. The doors on the construction lead outside of the patio to the backyard area. LPA observed games for the clients and outdoor furniture for seating. Licensee acknowledged that he did not inform Community Care Licensing of the alterations. The patio area appears safe.

Community Care Licensing received notification of incident that occurred at the property involving Client 2 (C2) becoming aggressive while outside in the backyard of the facility. Licensee and Administrator acknowledged that C2 caused damage to a neighbor’s property by knocking down a panel on the fence using their hands and elbows. The exact date is unknown. The incident was not reported to Community Care Licensing. LPA discussed reporting requirement with Licensee. Licensee stated that he understood.

The deficiencies are being cited pursuant to Title 22, Division 6, Chapter 1 of the California Code of Regulations on the attached LIC809D. An exit interview was conducted with Licensee Erwin Engay, copies of this report, LIC 811 Confidential Names List and the Licensee Rights (LIC9058 01/16) were provided to the licensee at the conclusion of the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Vicky Williamson
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/09/2022 03:24 PM - It Cannot Be Edited


Created By: Vicky Williamson On 11/09/2022 at 01:01 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: CHLOE'S HOME
FACILITY NUMBER: 374604245

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2022
Section Cited
CCR
80086(a)

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80086(a)Alterations to Existing Building or New Facilities a)Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
This requirement was not met as evidenced by: Based on Licensee’s own admission and LPA’s observation of the patio leading to the
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Licensee has agreed to provide an updated LIC 999 to Community Care Licensing by POC date.
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backyard. Patio was observed to be closed in with a 4 ft wall with lattice around the top area of the patio, except around both of the half doors. The alterations to the patio were not reported to CCL. This poses a potential safety risk to 3 out of 3 clients in care.
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Type B
11/15/2022
Section Cited
CCR80061(b)

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80061 b) Upon the occurrence, ... of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report ... shall be submitted to the licensing agency within seven days following ... event.
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Licensee and Administrator have agreed to review California Code of Regulation 80061 Reporting Requirements and provide a sign statement acknowledging that they have done so.

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This requirement was not met as evidenced by: Based on Licensee and Administrator's own admission, an incident involving C2 causing damage to the neighbors’s fence was not reported to CCL. This poses a potential safety risk to 3 out of 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:Vicky Williamson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022


LIC809 (FAS) - (06/04)
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