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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604401
Report Date: 05/16/2025
Date Signed: 05/16/2025 06:07:54 PM

Document Has Been Signed on 05/16/2025 06:07 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:CASA DEL MANANA LLCFACILITY NUMBER:
374604401
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, CRISTINAFACILITY TYPE:
735
ADDRESS:1190 5TH AVE., #B3TELEPHONE:
(858) 294-4278
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 4DATE:
05/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Licensee and Adminstrator Cristina HernandezTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee/Administrator Cristina Hernandez.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, and during today’s inspection the facility was full, with four (4) clients in care. LPA reviewed all client records. LPA reviewed all staff administrative and training records. LPA interviewed multiple clients and multiple staff who were present.

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 and screens, toilets, and showers were working. Extra linens, hygiene, and Personal Protective Equipment (PPE) supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

The facility’s ambient internal temperature was complaint at 71 F. Hot water temperature at taps normally accessible to clients were compliant in temperature: Kitchen Sink was 115.3 F, Bathroom #1 Sink was 115.9 F, Bathroom #2 Sink was 110.3 F, and Bathroom #3 Sink was 111 F. Refrigerators and freezers used to preserve perishable food were complaint in temperature. There were at least (2) days of perishable food and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present and in good condition.

[CONTINUED ON LIC 809-C]
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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 05/16/2025 06:07 PM - It Cannot Be Edited


Created By: Dang Nguyen On 05/16/2025 at 05:27 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 DEL MANANA LLC
FACILITY NUMBER: 374604401

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(b)(2)(C)
Infection Control Requirements
(b) In addition to subsection (a), when one or more clients in the facility are diagnosed with a contagious disease, the following shall apply:  (2) All staff and volunteers providing direct care to a client who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth.  PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection.  (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around clients and annually thereafter. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and manager interview, Licensee did not ensure 5 of 5 direct care staff [Staff #1 (S1) through Staff #5 (S5)] received training on PPE within the last year, as required. This posed a potential health risk to 4 of 4 clients (C1 through C4) in care.
POC Due Date: 06/16/2025
Plan of Correction
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Licensee agreed to train S1 through S5 on PPE. The training will include hands-on practice and will cover: a) handwashing, b) how and how often to disinfect commonly touched surfaces, c) how to correctly don and doff surgical masks, N-95 respirators, face shields, gowns, and gloves, d) how perform an N-95 seal check, and e) how to correctly set up a COVID-19 isolation bedroom. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and manager interview, Licensee did not ensure 5 of 5 direct care staff [Staff #1 (S1) through Staff #5 (S5)] received training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This posed a potential health risk to 4 of 4 clients (C1 through C4) in care.
POC Due Date: 05/16/2025
Plan of Correction
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Licensee agreed to have S1 through S5 complete First Aid training from a qualified source that issues a certification card valid for two (2) years. Licensee agreed to scan and E-mail the completion cards to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/16/2025 06:07 PM - It Cannot Be Edited


Created By: Dang Nguyen On 05/16/2025 at 05:27 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 DEL MANANA LLC
FACILITY NUMBER: 374604401

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(b)
Other Provisions
(b) If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and manager interview, Licensee did not ensure that 5 of 5 staff [Staff #1 (S1) through Staff #5 (S5)] received annual training on the facility's written emergency disaster plan, to include their individual responsibilities under it. This posed a potential safety risk to 4 of 4 clients (C1 through C4) in care.
POC Due Date: 06/16/2025
Plan of Correction
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Licensee agreed to train S1 through S5 on the facility's written LIC610D Emergency and Disaster Plan. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: CASA DEL MANANA LLC
FACILITY NUMBER: 374604401
VISIT DATE: 05/16/2025
NARRATIVE
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[CONTINUED FROM LIC 809]

The facility did not have a swimming pool (or similar body of water). The fireplace was sealed off and not being used. There were no open-faced heaters, toxic chemicals/poisons, or other hazardous objects accessible to clients. Smoke detectors, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. The facility's fire extinguisher was serviced within the last twelve (12) months. The facility’s license did not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present.

There was a locked area for storage of medication. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Per the Licensee, no firearms or ammunition were kept at the facility. Licensee presented proof of current business liability insurance and surety bond.

During a review of records, LPA observed, and manager interview confirmed: 5 of 5 facility staff did not have proof of current First Aid training certification through a qualified agency, as required. Licensee did not have proof that these same staff received training on the facility’s written Emergency Disaster Plan at time of hire or within the last year, as required. Licensee did not have proof that these same staff received training on Personal Protective Equipment (PPE) within the last year, as required.

Two (2) deficiencies were cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the LIC809-D pages). Plans of Correction were jointly developed with the Licensee. LPA issued two (2) Technical Violations (TV) regarding quarterly disaster drills for staff and regarding having a videoconferencing device at the facility available for client use (refer to the LIC9102-TV pages). LPA also provided Technical Assistance (TA) regarding refresher training for staff on California Mandated Reporting requirements (refer to the LIC9102-TA page).

An exit interview was conducted with Licensee/Administrator Cristina Hernandez, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV pages, the LIC9102-TA page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today's visit.
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC809 (FAS) - (06/04)
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