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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604273
Report Date: 07/08/2026
Date Signed: 07/08/2026 04:53:53 PM

Document Has Been Signed on 07/08/2026 04:53 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:CASA MAHALFACILITY NUMBER:
374604273
ADMINISTRATOR/
DIRECTOR:		FRAZIER, THERESAFACILITY TYPE:
740
ADDRESS:12631 CASA AVENIDATELEPHONE:
(858) 924-1136
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 5DATE:
07/08/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:03 PM
MET WITH: Caregiver Teresita Duclayan
Licensee Myrna Arcelao		TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced Case Management visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Caregiver Teresita Duclayan. Licensee Myrna Arcelao later joined the visit.

When LPA arrived at the facility there was a couch blocking the front door preventing LPA from entering. Per interview with caregiver the couch was placed in front of the door to prevent Resident #1 (R1) from eloping. [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] Caregiver reported they cannot keep an eye on R1 when tending to other residents because they were the only staff at the facility at that time. Caregiver immediately moved the couch to allow full access of the front door.

LPA observed R1 exit the facility in an elopement attempt while staff was in the kitchen. LPA followed R1 out and was able to keep R1 from going into the street. LPA stayed with R1 for some time, who refused to go back inside the facility. Caregiver came outside to stay with R1 at which point LPA went inside the facility and there were no other staff inside the facility to provide supervision to the other residents.

Additionally, LPA observed R1 to be restrained by a postural support. R1 was unable remove the restraint independently. A review of R1's records revealed that there is not a physician's order for postural support. Further, a review of all resident records revealed none of the residents had signed Personal Rights in their records.

Four deficiencies were observed and cited during todays visit per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages), including a Civil Penalty totaling $500 (refer to LIC 421IM). A plan of correction was jointly developed with Licensee Myrna Arcelao. Due to three Type A deficiencies being cited, LPA informed Licensee that an office meeting will be scheduled at a later date. An exit interview was conducted with Licensee, to whom a copy of this report, the LIC 809-D, LIC 421IM, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Angelica Boyles
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/08/2026 04:53 PM - It Cannot Be Edited


Created By: Angelica Boyles On 07/08/2026 at 01:59 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: CASA MAHAL
FACILITY NUMBER: 374604273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2026
Section Cited
CCR
87608(a)(3)

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Postural Supports(a)... Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need...shall be maintained in the resident’s record...
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Staff removed postural support restraint from R1 and Licensee stated she would obtain a physician's order and send to LPA by POC due date.
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This requirement was not met as evidenced by:
LPA observed R1 to be restrained to their wheelchair by postural supports wihout having a phsyician's order. This posed an immediate personal rights risk to 1 of 5 residents in care.
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Type A
07/09/2026
Section Cited
CCR87411(a)

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Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...
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Staff called for additional staff to come to the facility. Licensee will provide LPA with an updated staff schedule that includes at least two staff during the day by POC due date.
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This requirement was not met as evidenced by:
LPA observed only 1 staff on the facility premise which resulted in R1 attempted elopement. This posed an immediate health and safety risk to 5 of 5 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/08/2026 04:53 PM - It Cannot Be Edited


Created By: Angelica Boyles On 07/08/2026 at 02:33 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: CASA MAHAL
FACILITY NUMBER: 374604273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2026
Section Cited
CCR
87203

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Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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Staff immediately removed the couch from blocking the front door and stated it would not be placed in front of the door again. Therefore, this deficiency has been cleared.
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This requirement was not met as evidenced by:
LPA observed a couch blocking the front door. This caused an immediate health and safety risk to 5 of 5 resdients in care.
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Type B
07/24/2026
Section Cited
CCR87468(b)(1)(A)

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Personal Rights (b)...a resident...shall be personally advised of and given a copy of: (1) The personal rights (A)...and the signed copy shall be included in the resident's record.
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Licensee agreed to submit copies of all residents signed Personal Rights to LPA by POC due date.
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This requirement was not met as evidenced by:
Records reviewed revealed 5 out of 5 residents did not have a signed copy of the Perosnal Rights in their records. This poses a potential personal rights risk to 5 out of 5 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2026


LIC809 (FAS) - (06/04)
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