374604422-8-29-2024-08-AS-SMAZ-D8LRYQ-20240829132643

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604422
Report Date: 08/29/2024
Date Signed: 08/29/2024 01:26:49 PM

Document Has Been Signed on 08/29/2024 01:26 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:	LA JOLLA CASA PACIFICA		FACILITY NUMBER:	374604422
ADMINISTRATOR:	FERNANDEZ, JENNIFER		FACILITY TYPE:	740
ADDRESS:	5468 PACIFICA DR		TELEPHONE:	(858) 775-6935
CITY:	LA JOLLA	STATE: CA	ZIP CODE:	92037
CAPACITY:	6	CENSUS: 5	DATE:	08/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator Jennifer Fernandez		TIME COMPLETED:	01:35 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Administrator Jennifer Fernandez. The facility was licensed for a capacity of six (6) non-ambulatory residents, of which one may be bedridden in room number 5. The facility was also approved a hospice waiver for two (2) residents.

The LPA, accompanied by staff, 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, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, 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.

No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Carbon monoxide detectors, facility telephone, and Fire extinguisher(s) were present. A first aid kit(s) was readily accessible. Required licensing postings were observed in visible areas of the facility.

The LPA interviewed staff and reviewed multiple staff and resident records/files. Several personnel records were not present at the time of the visit. Additionally, a fire clearance violation regarding a bedridden resident was observed. These deficiencies were cited in an LIC 809D. An immediate $500 civil penalty was assessed in an LIC 421IM form. A plan of correction was jointly formulated with Fernandez.

An exit interview was conducted with Administrator Fernandez, to whom a copy of this report, LIC 811 Confidential names list, 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: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

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 08/29/2024 01:26 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: LA JOLLA CASA PACIFICA	FACILITY NUMBER: 374604422
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 3 staff (S1,S2, and S3), which poses/posed a potential health, safety or personal rights risk to 5 persons in care.
	POC Due Date: 08/29/2024
	Plan of Correction
1 2 3 4	Administrator agreed to provided the LPA the complete staff files for S1, S2, and S3, by 9/20/24.

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: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/29/2024 01:26 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: LA JOLLA CASA PACIFICA	FACILITY NUMBER: 374604422
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.72(c)

§1569.72 Residents requiring skilled nursing or intermediate care; bedridden residents (c) Notwithstanding paragraph (2) of subdivision (a), bedridden persons may be admitted to, and remain in, residential care facilities for the elderly that secure and maintain an appropriate fire clearance. A fire clearance shall be issued to a facility in which one or more bedridden persons reside if either of the following conditions are met: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of records, interviews, and observations, the licensee did not ensure one (R1) bedridden resident was in a bedridden approved bedroom, per the facility's fire clearance, which posed an immediate health, safety or personal rights risk to 1 of 5 persons in care.
	POC Due Date: 08/30/2024
	Plan of Correction
1 2 3 4	Administrator agreed to submit an LIC 200, and fire clearance request to change the status of R1’s bedroom from non-ambulatory to bedridden approved, by 8/30/24.

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: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

LIC809 (FAS) - (06/04)

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