374604610-2-9-2024-08-AS-RARZ-D2AVD9-20240209152024

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604610
Report Date: 02/09/2024
Date Signed: 02/09/2024 03:20:30 PM

Document Has Been Signed on 02/09/2024 03:20 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:	LIFE SAVER PLACE OF OCEANSIDE II		FACILITY NUMBER:	374604610
ADMINISTRATOR:	BALANQUIT, IEZL L.		FACILITY TYPE:	740
ADDRESS:	113 POLK ST		TELEPHONE:	(858) 284-9114
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	6	CENSUS: 5	DATE:	02/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Assistant Administrator Amy Undag		TIME COMPLETED:	03:25 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) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Assistant Administrator Amy Undag. LPA spoke with Licensee Zaldy Balanquit via telephone during the visit. The facility is licensed for a maximum capacity of 6 non-ambulatory residents, 1 of which may be bedridden. The facility has a waiver for 2 hospice residents. During today’s visit, the facility had a census of 5 non-ambulatory residents, 3 of which were receiving hospice services. The Administrator for the facility is Iezl Balanquit and their certificate was valid and current. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed near or on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. According to Amy Undag, no firearms or weapons are stored on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 111.6 degrees Fahrenheit in the kitchen, 108.0 degrees Fahrenheit in a private bathroom and 106.7 degrees Fahrenheit in a common bathroom. The facility’s internal temperature was measured at 72 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and label. LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 40 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. Continued on LIC809-C page...

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

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 3

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: LIFE SAVER PLACE OF OCEANSIDE II	FACILITY NUMBER: 374604610
	VISIT DATE: 02/09/2024

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

LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

LPA Ruiz provided technical assistance regarding submitting hospice exception requests and increases in hospice waivers on an LIC9102TV.

The Assistant Administrator will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days.

No deficiencies were cited on today’s date. An exit interview was conducted with Assistant Administrator Amy Undag, whose signature below confirms receipt of a copy of this report, the LIC9102TV, and the Licensee Appeal Rights (LIC9058 01/16).

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3