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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604582
Report Date: 08/12/2024
Date Signed: 08/12/2024 01:52:30 PM

Document Has Been Signed on 08/12/2024 01:52 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:UNIVERSAL HOMES IIIFACILITY NUMBER:
374604582
ADMINISTRATOR/
DIRECTOR:		BAUTISTA, EMMANUELFACILITY TYPE:
735
ADDRESS:1189 FIRST AVENUETELEPHONE:
(619) 299-7878
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 4DATE:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Caregiver Vilma Lopez and Director Yoanne CrisostomoTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Vilma Lopez. LPA then met with Director Yoanne Crisostomo, who arrived later during the visit.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, of whom all must be ambulatory. Per LPA observation, review of LIC602 Physician’s Reports, and staff interview: During today’s inspection, there were a total of four (4) clients in care, and all were ambulatory. The facility’s license did not include endorsements for delayed egress doors or secured perimeter, and neither of these were present during today’s visit.

LPA, accompanied by Licensee’s staff, 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. The facility’s ambient internal temperature was complaint at 76 F. Hot water temperature at taps accessible to clients were also compliant: Kitchen Sink was 107.6 F and Hallway Bathroom Sink was 107.3 F. The Staff Bathroom sink was 107.4 F. Appliances to preserve perishable food were compliant in temperature: Kitchen Refrigerator was 40 F and Kitchen Freezer was 0 F. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present.


[CONTINUED ON LIC 809-D]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2024
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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Document Has Been Signed on 08/12/2024 01:52 PM - It Cannot Be Edited


Created By: Dang Nguyen On 08/12/2024 at 12:55 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: UNIVERSAL HOMES III
FACILITY NUMBER: 374604582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024

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
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3
4
Based on records review and manager interview: Licensee did not ensure that 5 of 5 staff reviewed today [S1 through S5] were trained in the proper use of all required PPE prior to being around clients and annually thereafter. This posed a potential health risk to clients in care.
POC Due Date: 09/12/2024
Plan of Correction
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Licensee agreed to arrange for all five (5) current caregivers plus two (2) managers to receive training on how to properly don and doff PPE (to include surgical masks, N-95 respirators, faceshields, gowns, and gloves), and to document such training on an in-service sign-in sheet. Licensee agreed to E-mail LPA the sign-in sheet, 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
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Based on records review and manager interview: Licensee did not conduct an emergency/disaster drill at least quarterly for each shift. This posed a potential safety risk to 4 of 4 clients [C1 through C4] in care.
POC Due Date: 09/12/2024
Plan of Correction
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Licensee agreed to perform two (2) emergency/disaster drills - one will be on the AM shift (6:00 AM to 2:00 PM) and one will be on the overnight/NOC shift (10:00 PM to 6:00 AM) - and to document the results of both in writing. Licensee agreed to E-mail to LPA proof of drill completions, 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: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024


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: UNIVERSAL HOMES III
FACILITY NUMBER: 374604582
VISIT DATE: 08/12/2024
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[CONTINUED FROM LIC 809]

There were no hazardous objects/chemicals, active fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Confidential records were safely stored. 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, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguisher was serviced within the last twelve (12) months. A complete first aid kit was present and readily accessible. Required licensing postings were observed in visible areas of the facility. Licensee also presented proof of current/active business liability insurance and surety bond.

LPA reviewed files for all clients and all caregivers, and other administrative records. LPA also interviewed all clients and staff who were present during the visit. During this process, LPA observed, and manager interview confirmed: While Licensee performed quarterly emergency/disaster drills over the last year, such drills did not include the morning (AM) and overnight (NOC) shifts, as required. While Licensee had Personal Protective Equipment (PPE) on-site and staff were knowledgeable as to how to access and use PPE and how to set up a COVID-19 isolation bedroom, for 5 of 5 caregiver files reviewed, Licensee did not maintain proof that they were trained on PPE initially or annually, as required. None of the current clients in care had Prohibited Health Conditions or Restricted Health Conditions.

One (1) deficiency was cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D page). Plans of Correction were jointly developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding covers for trash cans (refer to the attached LIC 9102-TV page).

An exit interview was conducted with Crisostomo. A copy of this report, the LIC 809-D page, the LIC9102-TV page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today’s visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC809 (FAS) - (06/04)
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