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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604287
Report Date: 03/23/2023
Date Signed: 03/23/2023 01:02:15 PM


Document Has Been Signed on 03/23/2023 01:02 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:POWAY GARDENS SENIOR LIVING - THE SYCAMORESFACILITY NUMBER:
374604287
ADMINISTRATOR:WILLIAMS, DONELLEFACILITY TYPE:
740
ADDRESS:12738 MONTE VISTA RDTELEPHONE:
(858) 674-1255
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 0DATE:
03/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Donelle Williams, Executive DirectorTIME COMPLETED:
12:17 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced case management visit to follow-up on an incident reported to Community Care Licensing on March 3, 2022. LPA introduced herself, was granted entry into the facility, and met with Donelle Williams, Executive Director, to whom she disclosed the purpose of the visit. During today's visit, LPA issued a deficiency. Sherrylyn Anding, Resident Service Director, arrived during the visit.

LPA received a call from the facility on February 23, 2022 regarding a resident who was absent without official leave (AWOL). It was reported that Resident 1 (R1 - See LIC811 Confidential Names List) eloped from the facility earlier that same day. R1 was found about five (5) minutes later by R1’s primary care physician outside the facility. Facility was aware that R1’s physician's report indicated R1 had a diagnosis of dementia and could not leave unassisted. R1 has since moved out of the facility. Community Care Licensing received the incident report on March 2, 2022. Executive Director reported that facility has not had any residents since shortly after February 23, 2022

A deficiency is being cited on the LIC809-D in accordance with California Code of Regulations, Title 22. A plan of corrections was discussed and found to have been implemented before visit today. An exit interview was conducted with TITLE, a Plan of Corrections was discussed, and a copy of this report and Licensee Appeal Rights (LIC9058) were provided.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
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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Document Has Been Signed on 03/23/2023 01:02 PM - It Cannot Be Edited

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: POWAY GARDENS SENIOR LIVING - THE SYCAMORES
FACILITY NUMBER: 374604287

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2023
Section Cited

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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.
This requirement was not met as evidenced by:
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Prior to visit date, residents have not been living at facility since this incident. Licensee updated elopement policies to include calling police after 20 minutes, gave all staff radios, and do elopement drills once a month.
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Based on interviews and record review, the licensee did not have enough staff to provide the services necessary to meet resident needs persons in care which posed a potential health, safety, and personal rights risks to persons 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: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
LIC809 (FAS) - (06/04)
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