<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604547
Report Date: 04/20/2023
Date Signed: 04/20/2023 10:44:04 AM

Document Has Been Signed on 04/20/2023 10:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:L & M RESIDENTIAL #2FACILITY NUMBER:
374604547
ADMINISTRATOR:LARA, OSCARFACILITY TYPE:
735
ADDRESS:9028 DAVENRICH ST.TELEPHONE:
(619) 778-8949
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 4DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Caregiver Jose Lopez TIME COMPLETED:
10:45 AM
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) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with caregiver Jose Lopez. Licensee Oscar Lara later arrived to meet with LPA.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, all of whom can be non-ambulatory. During today’s inspection, there was a total of four (4) client in care. This facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by licensee, 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, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 70 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 108 F, Bathroom #1 sink was 108 F and Bathroom #2 sink was 111 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. There were no sharp objects, toxic chemicals/poisons, open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
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 4
Document Has Been Signed on 04/20/2023 10:44 AM - It Cannot Be Edited


Created By: Alyssa Ramirez On 04/20/2023 at 10:27 AM
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: L & M RESIDENTIAL #2
FACILITY NUMBER: 374604547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023

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 interview and record review, the licensee did not comply with the section cited above in 1 out of 2 staff (S1) which poses a potential health and safety risk to persons in care.
POC Due Date: 04/29/2023
Plan of Correction
1
2
3
4
Licensee will obtain S1's signed LIC503 and TB test results and place documents in S1's file by POC due date. Licensee will also email copies of S1's signed LIC503 and TB test results to LPA Ramirez by POC due date.
Type B
Section Cited
CCR
80066(a)(11)
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: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 2 staff (S1) which poses a potential health and safety risk to persons in care.
POC Due Date: 04/29/2023
Plan of Correction
1
2
3
4
Licensee will obtain S1's signed LIC503 and TB test results and place documents in S1's file by POC due date. Licensee will also email copies of S1's signed LIC503 and TB test results to LPA Ramirez by 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:Simon Jacob
LICENSING EVALUATOR NAME:Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/20/2023 10:44 AM - It Cannot Be Edited


Created By: Alyssa Ramirez On 04/20/2023 at 10:27 AM
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: L & M RESIDENTIAL #2
FACILITY NUMBER: 374604547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 4 clients (C1) which poses a potential health and safety risk to persons in care.
POC Due Date: 04/29/2023
Plan of Correction
1
2
3
4
Licensee will obtain C1's signed physician's report and TB test results and place documents in C1's file by POC due date. Licensee will also email copies of C1's signed physician's report and TB test results to LPA Ramirez by POC due date.
Type B
Section Cited
CCR
80069(c)(4)
Client Medical Assessments
(c) The medical assessment shall include the following: (4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 4 clients (C1) which poses a potential health and safety risk to persons in care.
POC Due Date: 04/29/2023
Plan of Correction
1
2
3
4
Licensee will obtain C1's signed physician's report and TB test results and place documents in C1's file by POC due date. Licensee will also email copies of C1's signed physician's report and TB test results to LPA Ramirez by 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:Simon Jacob
LICENSING EVALUATOR NAME:Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: L & M RESIDENTIAL #2
FACILITY NUMBER: 374604547
VISIT DATE: 04/20/2023
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
26
27
28
29
30
31
32
[CONTINUED FROM LIC 809]

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 extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and reviewed multiple staff and client records/files. LPA interviews did not raise any licensing concerns. Staff #1 (S1) file was missing LIC503 health screening and TB test. Client #1’s file (C1) was missing physician’s report and TB test. All other files contained required documents. Confidential records were stored in locked areas.

Deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plans of Correction were jointly developed with the licensee. An exit interview was conducted with Licensee Oscara Lara, to whom a copy of this report, the LIC 809-D and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

An exit interview was conducted with Lara, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4