374604552-3-27-2024-08-AS-AROS-D3S7NT-20240327214915

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604552
Report Date: 03/26/2024
Date Signed: 03/27/2024 09:49:34 PM

Document Has Been Signed on 03/27/2024 09:49 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:	ACORN OAKS MANOR II		FACILITY NUMBER:	374604552
ADMINISTRATOR:	LIMPIN, ALEXANDER		FACILITY TYPE:	740
ADDRESS:	6217 ACORN ST		TELEPHONE:	(619) 777-9674
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	14	CENSUS: 11	DATE:	03/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	House Manager Jamily Hallak		TIME COMPLETED:	06:10 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 (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility Med Tech Ivana Porras after identifying herself and stating the purpose of the inspection House Manager Jamily Hallak and Care Coordinator Maria Wiliams. A tour of the facility was conducted which included a sample of resident units, the dining area, common gathering areas, and food storage areas. There are no water features on site. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with the required furnishings. Overhead as well bedside lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. The facility is operating in accordance with their fire clearance. The smoke and carbon monoxide alarms were present in each building. Emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible in the medical rooms. Required licensing postings were observed in visible areas of the facility. PPE supplies are onsite. Indoor passageways were free from obstructions. Food was observed to be properly labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Centrally stored medications were properly stored and locked in medication carts. Medications were labeled and kept in compliance with label instructions. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ACORN OAKS MANOR II	FACILITY NUMBER: 374604552
	VISIT DATE: 03/26/2024

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[CONTINUED FROM LIC 809]

Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPAs conducted a review of In-service training procedures. LPA interviewed Houses Manager Jamily Hallak was assured transportation procedures as well as outside medical and dental assistance procedure are compliant.

There is large common rooms used for dining and activities. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. LPA interviewed staff and clients. LPA interviews did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Files reviewed contained required documents. Confidential records were stored in locked areas. House Manager Jamily Hallak presented proof of current/active business liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

No deficiencies were cited at the time of visit however, a Technical Violation was issued.

An exit interview was conducted with House Manager Jamily Hallak to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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