374604532-5-22-2023-08-AS-DNGN-CS3V28-20230522160242

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604532
Report Date: 05/22/2023
Date Signed: 05/22/2023 04:02:52 PM

Document Has Been Signed on 05/22/2023 04:02 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:	ROJA HOUSE		FACILITY NUMBER:	374604532
ADMINISTRATOR:	GILBO, JACKELINE		FACILITY TYPE:	735
ADDRESS:	4944 ROJA DRIVE		TELEPHONE:	(442) 888-7791
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY: 6		CENSUS: 2	DATE:	05/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Licensees Jackeline Gilbo and Alex Rodriguez		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Dang Nguyen and Riza Alvarez 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 Licensees Jackeline Gilbo and Alex Rodriguez. According to the facility’s license, the facility has a maximum capacity of six (6) clients, of which all must be ambulatory. During today’s inspection, there were a total of two (2) clients in care, of which both were ambulatory. The facility fire clearance did not include permissions for secured perimeter or delayed egress doors, and none of these were present during today’s visit. LPAs, accompanied by the licensees, 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 and 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. Hot water temperatures at taps accessible to clients were compliant: Kitchen sink was 109.8 F, Bathroom #1 sink was 109.8 F, Bathroom #2 sink was 109 F, and Bathroom #3 sink was 108.7 F. The facility’s ambient internal temperature was complaint at 72 F. Kitchen and Garage refrigerator temperatures were both complaint at 39 F. Kitchen and Garage freezer temperatures were both compliant at 0 F. 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. Kitchen appliances were working. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

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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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: ROJA HOUSE	FACILITY NUMBER: 374604532
	VISIT DATE: 05/22/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Confidential staff and client records were stored in locked areas.

No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Licensees presented proof of current/active business liability insurance and surety bond.

LPAs interviewed multiple staff and clients and reviewed multiple staff and client records/files. LPA’s interviews of clients did not raise any licensing concerns.

Records reviewed and staff interviews showed: Licensee did not maintain a LIC503 Health Screening or equivalent written physical for Staff #1's (S1's) in their employee file. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] Licensee did not ensure S1 and Staff #2 (S2) had evidence of First Aid training in their employee files. Licensee did not ensure that Client #1 (C1) had a completed LIC602 Physician’s Report or equivalent medical assessment document in their client file. Lastly, disaster drills for each shift had not been conducted on a quarterly basis.

Deficiencies were cited per California Code of Regulations, Title 22 and California Health and Safety Code (refer to the attached LIC 809-D pages). Plans of Correction was jointly developed with the licensee.

An exit interview was conducted with Gilbo, to whom a copy of this report, the LIC 809-D pages, 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: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 05/22/2023 04:02 PM - It Cannot Be Edited

Created By: Dang Nguyen On 05/22/2023 at 03:04 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: ROJA HOUSE	FACILITY NUMBER: 374604532
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

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: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed and staff interviews, licensee did not maintain a health screening in the personnel record for 1 of 3 staff (S1), which posed a potential health and safety risk to persons in care.
	POC Due Date: 06/21/2023
	Plan of Correction
1 2 3 4	Licensee agreed to obtain a completed health screening for S1, and to E-mail a copy of it 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
1 2 3 4	Based on records reviewed and staff interviews, licensee did not ensure that 2 of 3 staff (S1 and S2) received training in first aid from persons qualified by agencies including but not limited to the American Red Cross, which posed a potential health and safety risk to persons in care.
	POC Due Date: 06/21/2023
	Plan of Correction
1 2 3 4	Licensee agreed to arrange for S1 and S2 to complete first aid training through a qualified agency, and to E-mail copies/images of their certification 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.

SUPERVISOR'S NAME:

Lizzette Tellez

LICENSING EVALUATOR NAME:

Dang Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/22/2023 04:02 PM - It Cannot Be Edited

Created By: Dang Nguyen On 05/22/2023 at 03:04 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: ROJA HOUSE	FACILITY NUMBER: 374604532
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.2(b)(1)(C)

Needs and Services Plan

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and staff interview, licensee did not maintain a written medical assesment for 1 of 2 clients (C1), which posed a potential health and safety risk to persons in care.
	POC Due Date: 06/21/2023
	Plan of Correction
1 2 3 4	Licensee agreed to obtain a complete and signed written medical assessment for C1, and to E-mail a copy of it to LPA by the POC due date.

Type B

Section Cited

HSC

1565(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and staff interview, licensee did not conduct an emergency/disaster drill at least quarterly for each shift, which posed a potential safety risk to 2 of 2 clients in care (C1 and Client #2).
	POC Due Date: 06/21/2023
	Plan of Correction
1 2 3 4	Licensee agreed to conduct one emergency/disaster drill on its AM, PM, and NOC/overnight shifts, respectively. Licensee agreed to E-mail copies of the drill logs 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.

SUPERVISOR'S NAME:

Lizzette Tellez

LICENSING EVALUATOR NAME:

Dang Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

LIC809 (FAS) - (06/04)

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