374604534-9-10-2025-08-AS-DNGN-DLDV2R-20250910160336

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604534
Report Date: 09/10/2025
Date Signed: 09/10/2025 04:04:04 PM

Document Has Been Signed on 09/10/2025 04:04 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:	SJIC II - HOME & CARE		FACILITY NUMBER:	374604534
ADMINISTRATOR/ DIRECTOR:	CAROLINE MACARAEG		FACILITY TYPE:	735
ADDRESS:	1125 FOXBORO AVE		TELEPHONE:	(619) 216-0019
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91911
CAPACITY: 4		CENSUS: 4	DATE:	09/10/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Caregiver Marlinda Anyayahan and Licensee/Administrator Caroline Macaraeg		TIME VISIT/ INSPECTION 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 Analyst (LPA) Dang Nguyen made 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 Caregiver Marlinda Anyayahan. LPA then met with Licensee/Administrator Caroline Macaraeg, who arrived shortly after. According to the facility’s license, the facility has a maximum capacity for four (4) clients, of whom all must be ambulatory. Per LPA observation, LIC602 Physician’s Reports, and interviews: During today’s inspection, there were a total of four (4) clients in care, and all were ambulatory. LPA interviewed multiple staff and multiple clients. LPA also reviewed the care records for all clients, and the personnel and training files for all active staff. LPA, accompanied by Licensee, toured the interior and exterior of the facility and inspected all common areas and bedrooms. During the facility tour, LPA observed: Inside the facility’s laundry room (which was left unlocked with door ajar), there was one 200 fluid ounce container of laundry detergent and some fabric softener accessible to clients. In the facility’s garage (which was unlocked and contains exercise machines used by clients), there was a can of penetrating lubricant accessible to clients. In the facility’s backyard, there was a gardening spade with a pointed metal blade longer than six inches accessible to clients. [During today's visit, facility staff immediately secured/locked away each of the above items.] Beyond the above issues, 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, toilet, and shower were all working. Extra linens and hygiene supplies were present. [CONTINUED ON LIC 809-C]

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025

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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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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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: SJIC II - HOME & CARE	FACILITY NUMBER: 374604534
	VISIT DATE: 09/10/2025

NARRATIVE

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[CONTINUED FROM LIC 809] 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 76 F. Where tested, hot water temperature at taps accessible to clients were compliant in temperature: Kitchen Sink was 114.1 F and Shared Bathroom Sink was 117.3 F. Appliances to preserve perishable food were also compliant in temperature. There was at least two (2) days of perishable food and at least seven (7) days of non-perishable food, all safely stored. Cooking/dining equipment and utensils were present and in good condition. The facility’s fireplace was screened as required. The facility’s fire extinguisher was serviced within the last twelve (12) months, as required. Carbon monoxide detectors, smoke alarms, night lights, and emergency lighting were all working. There were no pools or similar bodies of water on the premises. There were no medications or open-faced heaters accessible to clients. Confidential records were stored in locked areas. Per the Licensee, no firearms or ammunition are kept at the facility. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter doors, and neither of these were present. Required licensing postings were observed in visible areas of the facility. Licensee presented proof of current business liability insurance and surety bond.

Client care files contained the required records. During a review of training records, LPA observed, and manager interview confirmed: Licensee did not have proof that staff were trained on Personal Protective Equipment (PPE) and the facility’s written Emergency Disaster Plan within the last twelve (12) months, as required. However, there were reserve supplies of PPE present, and Licensee did perform quarterly disaster drills over the last year.

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 one (1) Technical Violation (TV) regarding having a videoconferencing device at the facility dedicated for resident use (refer to the LIC9102-TV page). 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 Caroline Macaraeg, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV page, 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: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/10/2025 04:04 PM - It Cannot Be Edited

Created By: Dang Nguyen On 09/10/2025 at 03:00 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: SJIC II - HOME & CARE	FACILITY NUMBER: 374604534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2025

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
1 2 3 4	Based on record review and manager interview, Licensee did not ensure 5 of 5 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 [Client #1 (C1) through Client #4 (C4)] in care.
	POC Due Date: 10/10/2025
	Plan of Correction
1 2 3 4	Licensee agreed to train all current staff 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

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, Licensee did not ensure that cleaning solutions and items that could pose a danger if readily available to clients, were stored where inaccessible to clients. This posed a potential health and safety risk to 4 of 4 clients [Client #1 (C1) through Client #4 (C4)] in care.
	POC Due Date: 10/10/2025
	Plan of Correction
1 2 3 4	During today's visit, staff immediately secured/locked away the cleaning solutions and hazardous item referenced in the report. Licensee agreed to retrain all staff on what items constitute safety hazards to clients, and their expectation that they remain locked away when not in active use by staff. Licensee agreed to E-mail the training sign-in sheet 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.

	Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:

	Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 09/10/2025 04:04 PM - It Cannot Be Edited

Created By: Dang Nguyen On 09/10/2025 at 03:00 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: SJIC II - HOME & CARE	FACILITY NUMBER: 374604534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2025

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
1 2 3 4	Based on records review and manager interview, Licensee did not have proof of training being provided to 5 of 5 staff [Staff #1 (S1) through Staff #5 (S5)] on the facility's written emergency and disaster plan, within the last year. This posed a potential health and safety risk to 4 of 4 clients [Client #1 (C1) through Client #4 (C4)] in care.
	POC Due Date: 10/10/2025
	Plan of Correction
1 2 3 4	Licensee agreed to train all current active and backup staff on the facility's LIC610D Emergency Disaster Plan, and to E-mail the training sign-in sheet to LPA, by the POC due date. Going forward, Licensee agreed to repeat this training at least annually.

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.

	Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:

	Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025

LIC809 (FAS) - (06/04)

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