374604384-3-21-2023-08-AS-DNGN-CQ622U-20230321170118

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604384
Report Date: 03/21/2023
Date Signed: 03/21/2023 05:01:34 PM

Document Has Been Signed on 03/21/2023 05:01 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:	JOSEPHINE'S HOME 2		FACILITY NUMBER:	374604384
ADMINISTRATOR:	SO, JOSEFINA M.		FACILITY TYPE:	735
ADDRESS:	1452 MULLIGAN HILL ST		TELEPHONE:	(619) 948-7101
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91913
CAPACITY: 4		CENSUS: 3	DATE:	03/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Licensee Josefina So		TIME COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Dang Nguyen and Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Licensee Josefina So.

The facility is currently licensed for a maximum capacity of four (4) clients, of which three (3) may be non-ambulatory. Non-ambulatory clients must be assigned to Bedrooms #1 and #5 on the first floor, as per the facility sketch. On the date of inspection, the facility had three (3) clients in care. Two (2) of these clients were non-ambulatory and both resided in the correct/approved bedroom(s). This facility does not have a secured perimeter or delayed egress doors.

During today’s visit, LPAs, accompanied by the licensee, toured the interior and exterior of the facility and inspected each room. Staff and clients were interviewed, and staff and client records were reviewed. LPAs briefly left the facility to take a lunch break between 12:00 PM and 1:00 PM.

The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Client bedrooms contained the required furnishings. There were extra linens and hygiene supplies present. The facility’s ambient internal temperature was 69 degrees F. Doors, windows and screens, toilets, and showers were in working order. Water temperature at taps accessible to clients were complaint: Kitchen was 109 F and Bathrooms #1-5 were also each 109 F. The facility had at least 2 days of perishable food and at least 7 days non-perishable food, as well as required cooking/dining equipment and utensils. Refrigerator temperature was 35 F, and freezer temperature was -2 F.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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 03/21/2023 05:01 PM - It Cannot Be Edited

Created By: Dang Nguyen On 03/21/2023 at 01:48 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: JOSEPHINE'S HOME 2	FACILITY NUMBER: 374604384
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85087(a)(4)

Building and Grounds

(4) No client bedroom shall be used as a public or general passageway to another room, bath or toilet. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above for 2 out of 3 clients (C1 and C2), which posed a potential personal rights risk to persons in care.
	POC Due Date: 04/20/2023
	Plan of Correction
1 2 3 4	Licensee agreed to relocate their desk/office, removing it from the shared bathroom of C1 and C2, and to another location. Following the move, licensee agreed to send a photograph of C1 and C2's bathroom to LPA, by the POC due date.

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

LICENSING EVALUATOR NAME:

Dang Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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: JOSEPHINE'S HOME 2	FACILITY NUMBER: 374604384
	VISIT DATE: 03/21/2023

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[CONTINUED FROM LIC 809]

The facility has sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. There were locked areas for storage of medication. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Per the licensee, no firearms or ammunition are stored at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. Fire extinguisher(s) were inspected/serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. The staff and client files which LPAs reviewed contained the required records/documents. Licensee presented proof of current business liability insurance and surety bond.

During today’s visit, LPAs observed that licensee had placed their personal work desk and office within a portion of the master bathroom connected to Bedroom #1, where Client #1 (C1) and Client #2 (C2) reside. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] This required staff to pass through Bedroom #1 to access said desk/office area. Per regulation, “No client bedroom shall be used as a public or general passageway to another room…”

A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with So, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC809 (FAS) - (06/04)

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