374604362-11-29-2023-08-AS-SMAZ-CY2W4T-20231129155802

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604362
Report Date: 11/29/2023
Date Signed: 11/29/2023 03:58:07 PM

Document Has Been Signed on 11/29/2023 03:58 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:	UC CARE SENIOR LIVING II		FACILITY NUMBER:	374604362
ADMINISTRATOR:	DEREK POSADA		FACILITY TYPE:	740
ADDRESS:	3739 MILLIKIN AVE		TELEPHONE:	(858) 203-1160
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92122
CAPACITY:	6	CENSUS: 6	DATE:	11/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Caregivers Beatriz Jimenez and Alfonso Serrano		TIME COMPLETED:	04:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection Visit. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Beatriz Jimenez. The facility was licensed for a capacity of six (6) residents, of which all could be non-ambulatory, one (1) may be bedridden; and an approved hospice waiver for five (5) residents.

Accompanied by Caregiver Jimenez, the LPA toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens, and Personal Protective Equipment were present. The facility had sufficient space and equipment to facilitate dining, visitation, meetings, and client activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, and stored in a locked area.

No pools, nor bodies of water on the premises. Per staff, no firearms or ammunition were kept at the facility. Facility telephone was operational, and required licensing postings were observed in visible areas of the facility.

The LPA interviewed staff and reviewed multiple staff and client records/files. First aid certificates for two staff had expired at the time of the visit. This deficiency was cited in an LIC 809D, and a plan of correction was jointly formulated with Caregiver Jimenez.

An exit interview was conducted with Caregiver Jimenez, to whom a copy of this report, LIC 809D and the Licensee/Appeal Rights (LIC9058), were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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 11/29/2023 03:58 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: UC CARE SENIOR LIVING II	FACILITY NUMBER: 374604362
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of records, the licensee did not comply with the section cited above in 2 staff, which poses/posed a potential health, safety or personal rights risk to 6 of 6 persons in care.
	POC Due Date: 11/29/2023
	Plan of Correction
1 2 3 4	Caregiver Jimenez agreed to have staff obtain first aid training/certificates and submit proof to the LPA, by 12/29/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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