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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604439
Report Date: 05/30/2023
Date Signed: 05/30/2023 01:51:44 PM


Document Has Been Signed on 05/30/2023 01:51 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:KELLY'S CEDAR VILLAFACILITY NUMBER:
374604439
ADMINISTRATOR:WELKER, GARRETTFACILITY TYPE:
740
ADDRESS:1341 BOYLE AVENUETELEPHONE:
(619) 504-5049
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 5DATE:
05/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator, Garrett WelkerTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 5/30/2023 at 10:50 a.m. LPA was granted entry and met with Administrator, Garrett Welker, who was informed of the purpose of the visit. At the time of the visit there was (3) staff and (5) residents present.

The facility is a two story home with (9) bedrooms and (8) bathrooms and (1) shower room. The facility has an attached garage. The facility has a second floor basement with (3) bedrooms and (1) bathroom, the first floor had (6) bedrooms and (6) bathrooms. No pools or firearms are being kept at the facility. The residents served are elderly ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and client interviews. LPA observed the following:

Infection Control: The LPA observed hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.



Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients in pantry closet. The smoke detector and carbon monoxide was operational, and the hot water temperature 108F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator, possesses a current administrator's certificate.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KELLY'S CEDAR VILLA
FACILITY NUMBER: 374604439
VISIT DATE: 05/30/2023
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Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (4) resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: Medication was observed to be locked in a tool chest, however LPA found unlocked medication in the facility activity room for Resident #1 (R1). This deficiency was documented along with plan of correction. LPA reviewed resident medication and found that facility was transferring medication into weekly pill boxes for Resident #2 (R2). This deficiency was documented along with plan of correction.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan which met the department requirements. LPA reviewed documentation showing the facility's last fire drill, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit with all required items.

An exit interview was conducted where a copy of this report along with appeal rights and deficiency pages were provided to the Administrator, Garrett Welker.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/30/2023 01:51 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: KELLY'S CEDAR VILLA
FACILITY NUMBER: 374604439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(1)(C)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with R1's medication being kept unlocked in the facility activity room. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2023
Plan of Correction
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The adminsitrator agreed to send the LPA a written and signed plan on how they plan to store medications for R1 to ensure other resident's safety. This is due 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.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 05/30/2023 01:51 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: KELLY'S CEDAR VILLA
FACILITY NUMBER: 374604439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with R2's medication being transferred into weekly pill box. Thus which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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The Administrator agreed to retrain staff on the regulation cited above and send the LPA a staff sign in sheet of training attended with staff signatures 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.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5