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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604271
Report Date: 11/15/2021
Date Signed: 11/16/2021 10:12:46 AM

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:SANTEE ELDERLY CAREFACILITY NUMBER:
374604271
ADMINISTRATOR:DERMODY, THOMASFACILITY TYPE:
740
ADDRESS:9069 INVERNESS RDTELEPHONE:
(619) 929-9939
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY:6CENSUS: 6DATE:
11/15/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:02 PM
MET WITH:Licensee, Thomas DermodyTIME COMPLETED:
03:34 PM
NARRATIVE
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Licensing Program Analyst (LPA), Kristina Ryan conducted a case management visit to cite for a deficiency observed while completing a records review for a complaint. LPA met with Licensee, Thomas Dermody, and discussed the purpose of the visit.

While reviewing records for a complaint, LPA found that 3 residents with a diagnosis of dementia, did not have an updated annual medical assessment and an annual reappraisal.

A deficiency is being cited pursuant to Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D.

An exit interview was conducted, and a plan of correction was jointly made with the licensee. A copy of the report, LIC 809-D, and Licensee/Appeal Rights (LIC 9058 01/16) will be emailed to the licensee following the visit. Acknowledgement of receipt of the documents is requested upon receipt
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
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: SANTEE ELDERLY CARE
FACILITY NUMBER: 374604271
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2021
Section Cited

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87705 Care of Persons with Dementia (c) (5) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not as evidenced by;
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Based on record review and interviews, the licensee did not ensure that annual medical reappraisals were done for 3 out of 3 residents with dementia, which poses a potential Health risk to residents 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 JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021
LIC809 (FAS) - (06/04)
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