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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604508
Report Date: 06/09/2023
Date Signed: 06/09/2023 03:20:48 PM


Document Has Been Signed on 06/09/2023 03:20 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:COGIR OF FALLBROOKFACILITY NUMBER:
374604508
ADMINISTRATOR:ZEPEDA, JESSICAFACILITY TYPE:
740
ADDRESS:1735 SO MISSION ROADTELEPHONE:
(760) 232-6800
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:128CENSUS: 35DATE:
06/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Jessica ZepedaTIME COMPLETED:
03:27 PM
NARRATIVE
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 Licensing Program Analyst (LPA), Jacqueline Shaw Ross and Licensing Program Manager,(LPM) Joel Esquivel conducted an unannounced visit to the facility for the purpose of a required annual inspection. LPA and LPM met with Executive Director, Jessica Zepeda and explained the nature of the visit and was granted entry into the facility. The facility was inspected inside and out. At the time of the visit, 31 staff and 35 clients were noted to listed. LPA Shaw Ross conducted staff and client interviews.

The facility is two story and has 103 rooms. The facility appears clean and free of odors. LPA observed that the facility did not have any health and safety issues. Staff present have criminal record clearances and are appropriately associated to the facility. Client bedrooms are clean and appropriately furnished. Food supplies are sufficient. LPA observed all toxic chemicals and other hazards secured and inaccessible to clients. Medications are centrally stored in a locked cabinet . Furniture in the facility is in good repair. Outdoor space is free of hazards.

LPM and LPA inspected the staff and client records. Staff files had the required documentation including First Aid Certifications and training documents. LPA inspected medications and during the inspection, the LPA observed the following deficiencies:

- Medications were not being dispensed as required - LPA observed medication in bubble packs that were not popped, but the Medication Records system used stated that the medication had been dispensed.
- The facility had PRN medication on hand, such as, Preparation H topical cream - the facility did not have said medication on list.

Based on observations made by LPA, the facility was cited and deficiencies noted on LIC809D. An exit interview was conducted with the Executive Director Jessica Zepeda and a copy of this report, LIC809D, and appeal rights was provided.
SUPERVISOR'S NAME: Leslie MendivelesTELEPHONE: (951) 782-4137
LICENSING EVALUATOR NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
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 2


Document Has Been Signed on 06/09/2023 03:20 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: COGIR OF FALLBROOK
FACILITY NUMBER: 374604508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Medications were not being dispensed as required - LPA observed medication in bubble packs that were not popped, but the Medication Records system used stated that the medication had been dispensed.
POC Due Date: 06/16/2023
Plan of Correction
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Administrator and Health and Wellness Director will provide a in-service and re-training to the Medication technicians.
Type B
Section Cited
CCR
87465(d)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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The facility had PRN medication on hand, such as, Preparation H topical cream - the facility did not have said medication on list.
POC Due Date: 06/16/2023
Plan of Correction
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Administrator and Health and Wellness Director will provide a in-service and re-training to the Medication technicians.
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: Leslie MendivelesTELEPHONE: (951) 782-4137
LICENSING EVALUATOR NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
LIC809 (FAS) - (06/04)
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