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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604270
Report Date: 12/12/2024
Date Signed: 12/12/2024 05:02:18 PM

Document Has Been Signed on 12/12/2024 05:02 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:ALLIANCE GUEST HOMEFACILITY NUMBER:
374604270
ADMINISTRATOR/
DIRECTOR:		CHONG, CANDYFACILITY TYPE:
735
ADDRESS:1525 OLEANDER AVENUETELEPHONE:
(619) 349-3204
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 3DATE:
12/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Lead Caregiver Elizabeth De Guia and Administrator Henrietta “Candy” ChongTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Lead Caregiver Elizabeth De Guia. LPA also met with Licensee/Administrator Henrietta “Candy” Chong, who arrived later during the visit.

According to their latest LIC602 Physician’s Report, C1 was diagnosed with Mild Intellectual Disability and Schizophrenia. LPA observed that C1 was alert, aware, and oriented, and able to be qualified as a witness for this case.

San Diego Regional Center (SDRC) records and interviews of multiple facility staff and an outside source aligned to show: On the afternoon of 11-27-2024, Client #1 (C1) was briefly alone at the facility without staff. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report.] During this time, S1’s set of facility keys were left atop of a cabinet about five feet in height (which C1 was tall enough to reach).

During today’s visit, LPA observation, confirmed by staff interviews, showed the keys in question corresponded to cabinets at the facility, which contained, in part: five (5) sharp cooking knives and a pair of full-length scissors, and over a dozen (12) cleaning chemicals/disinfectants/detergents that would be toxic if ingested. Per interview of C1: During the time they were alone at the facility, they did not pay attention to C1’s keys nor attempt to open any of the cabinets in question. No harm or injury befell them.


[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ALLIANCE GUEST HOME
FACILITY NUMBER: 374604270
VISIT DATE: 12/12/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Chong and De Guia. A copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today’s visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2024 05:02 PM - It Cannot Be Edited


Created By: Dang Nguyen On 12/12/2024 at 04:31 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: ALLIANCE GUEST HOME
FACILITY NUMBER: 374604270

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2024
Section Cited
CCR
80087(g)

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80087 Buildings and Grounds: “(g) Disinfectants, cleaning solutions, poisons… and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.” This requirement was not met, as evidenced by:
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Records and interviews showed Licensee already individually counseled S1 regarding the incident and provided formal remedial training to S1 on their job duties (to include securing their keys, chemicals/disinfectants/detergents, sharp objects, and other hazardous items). LPA interview of S1 showed they comprehended the lessons learned. The Plan of Correction is thus Satisfied.
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Based on records and interviews, during the incident in question, Licensee did not ensure disinfectants, cleaning solutions, poisons, and other items that could pose a danger if readily available to clients were stored where inaccessible to clients. This posed a potential health and safety risk to 1 of 3 clients (C1) 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
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