374603622-3-11-2024-08-AS-AROS-D39R99-20240311124911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603622
Report Date: 03/11/2024
Date Signed: 03/11/2024 12:49:22 PM

Document Has Been Signed on 03/11/2024 12:49 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:	ALTHAIA HOME		FACILITY NUMBER:	374603622
ADMINISTRATOR:	CONSOLACION SHANKULA		FACILITY TYPE:	735
ADDRESS:	7122 MOUNT VERNON ST.		TELEPHONE:	(619) 639-7970
CITY:	LEMON GROVE	STATE: CA	ZIP CODE:	91945
CAPACITY:	6	CENSUS: 6	DATE:	03/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Care Giver Ambrosio Cacanindin		TIME COMPLETED:	01:15 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 conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself, and discussed the purpose of the visit with Care Giver Ambrosio Cacanindin. According to the facility’s license, the facility has a maximum capacity of six (6) clients of which are ambulatory This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. Most pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors,, 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 compliant. 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, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

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 03/11/2024 12:49 PM - It Cannot Be Edited

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: ALTHAIA HOME	FACILITY NUMBER: 374603622
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times safety and well-being of clients, employeesand visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of client bedroom shards of glass are present in window, the licensee did not comply with the section cited above 1 of 5 client bedrooms which poses an immediate health, safety or personal rights risk to persons (C1-C6) in care.
	POC Due Date: 03/11/2024
	Plan of Correction
1 2 3 4	LPA asked caregiver to remove shards of glass surronding inside of client's bedroom window. Immidiate risk was resolved during visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

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

FACILITY NAME: ALTHAIA HOME	FACILITY NUMBER: 374603622
	VISIT DATE: 03/11/2024

NARRATIVE

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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 were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPAs interviewed multiple staff and clients and reviewed multiple staff and client records/files. LPA’s interviews did not raise any licensing concerns. The files which LPAs reviewed contained required documents. Licensee also presented proof of current/active business liability insurance and surety bond.

During today’s visit, LPAs observed, Client’s room in front hall back room, one window that had broken shards of glass surrounding the inside of the window. Window did have plexiglass installed instead of glass due to previous broken window. Shards were glass.

A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the care giver. An exit interview was conducted with Care Giver Ambrosio Cacanindin, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC809 (FAS) - (06/04)

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