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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604671
Report Date: 03/10/2025
Date Signed: 03/10/2025 03:13:42 PM

Document Has Been Signed on 03/10/2025 03:13 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 HOMESFACILITY NUMBER:
374604671
ADMINISTRATOR/
DIRECTOR:		CRISOSTOMO, YOANNEFACILITY TYPE:
735
ADDRESS:1128 ALPINE AVE.TELEPHONE:
(619) 300-8404
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 4DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Licensee/Administrator Yoanne Crisostomo and Guadalupe “Lupita” Perez-Barraza TIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted 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 Co-Licensee/Administrator Yoanne Crisostomo. LPA also met with House Manager Guadalupe “Lupita” Perez-Barraza, 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. According to LIC602 Physician’s Reports, staff interviews, and LPA observation: During this annual inspection, there were a total of four (4) clients in care, and all were ambulatory per their respective doctors. The facility’s license did not include endorsements for delayed-egress doors or secured perimeter, and neither of these were used at the facility.

During this inspection, LPA interviewed multiple clients and multiple staff. LPA reviewed the care and administrative records for all clients and the personnel and training files for all staff. The files reviewed were complete/complaint. LPA also toured the interior and exterior of the facility and inspected all common areas and bedrooms. 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 working. Extra linens, hygiene, and Personal Protective Equipment (PPE) 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 69 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen Sink was 109.4 F, Bathroom #1 Sink was 112.6 F, and Bathroom #2 Sink was 114.3 F. Appliances to preserve perishable food were also complaint in temperature: both Kitchen Refrigerators were 40 F, and both Kitchen Freezers were 0 F. [CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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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Document Has Been Signed on 03/10/2025 03:13 PM - It Cannot Be Edited


Created By: Dang Nguyen On 03/10/2025 at 01:58 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
FACILITY NUMBER: 374604671

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

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
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Based on records review and manager interviews, Licensee did not ensure that 4 of 6 direct care staff (S1 through S4) were trained on the facility's written emergency and disaster plan at least annually. This posed a potential safety risk to 4 of 4 clients (Client #1 through Client #4) in care.
POC Due Date: 04/10/2025
Plan of Correction
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Licensee agreed to train S1 through S4 on the facility's written LIC610D Emergency and Disaster Plan, and their responsibilities under it. Licensee agreed 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 for all staff.
Type B
Section Cited
CCR
80075(l)(1)
80075 Health Related Services: “(l) Prescription medications…which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client. (1) Both shall sign a record, to be retained for at least one year, which lists the following: (A) Name of the client; (B) The prescription number and the name of the pharmacy; (C) The drug name, strength and quantity destroyed; (D) The date of destruction.”

This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on records review and manager interviews, Licensee did not earlier maintain a signed written record of clients’ prescription medications which had been destroyed/discarded. This posed a potential personal rights risk to 4 of 4 clients (Client #1 through Client #4) in care.
POC Due Date: 03/10/2025
Plan of Correction
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CCLD will not require Licensee to recreate records for medications already destroyed/discarded. Based on manager interviews, only the Administrator (S1) and House Manager (S2) are responsible for this task. During today’s visit, LPA trained both S1 and S2 on the regulatory requirement, satisfying the Plan of Correction. Going forward, Licensee agreed to ensure the Centrally Stored Medication Destruction Record form is populated, whenever this task occurs.
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: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


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
FACILITY NUMBER: 374604671
VISIT DATE: 03/10/2025
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[CONTINUED FROM LIC 809] There were at least (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 and in good condition.

The facility did not have any swimming pools or bodies of water. The facility’s fireplace was screened, as required. There were no open-faced heaters accessible to clients. Smoke detectors, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. The facility's fire extinguisher was serviced within the last twelve (12) months. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Per the Licensee, no firearms or ammunition were kept at the facility. Licensee presented proof of current business liability insurance and surety bond.

Records review, confirmed by multiple manager interviews, showed: Licensee did not ensure that four (4) of the six (6) current direct care staff [Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), and Staff #4 (S4)] had received training on the facility’s written Emergency and Disaster Plan within the last twelve (12) months, as was required. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] Also, Licensee previously destroyed/discarded obsolete or expired medications for the four (4) clients in care. These actions were performed by the Administrator (S1), accompanied by the House Manager (S2) as witness. However, Licensee did not maintain a signed and written record listing the name of the client, the prescription numbers and name of the pharmacy, the drug names, strength, and quantity destroyed, and the date of destruction, as required.

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 LIC809-D page). Plans of Correction were jointly developed with the Licensee. LPA also provided Technical Assistance (TA) regarding auditory staff alert devices on exit doors (refer to the LIC9102-TA page).

An exit interview was conducted with Crisostomo and Perez-Barraza, to whom a copy of this report, the LIC 809-D page, the LIC9102-TA page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today's visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
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