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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603643
Report Date: 06/04/2024
Date Signed: 06/04/2024 02:28:26 PM


Document Has Been Signed on 06/04/2024 02:28 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:ST. PAUL'S PLAZAFACILITY NUMBER:
374603643
ADMINISTRATOR:STRATMAN, KIMFACILITY TYPE:
740
ADDRESS:1420 E PALOMAR STREETTELEPHONE:
(619) 591-0600
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY:300CENSUS: 141DATE:
06/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Assistant Administrator Maria SanoTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Assistant Administrator Maria Sano.

Today's visit was in response to a licensee self-reported incident. An Unusual Incident Report was received at the CCLD San Diego Regional Office on 4/2/2024. [See LIC 811 Confidential Names List for a description of resident]. Per the self-reported document, facility staff blended soup and offered it to R1. R1 began coughing and staff realized that soup contained seafood contents. Staff called 911 due to R1 being allergic to fish. R1 was transported to the hospital for evaluation.

Review of records revealed that R1's physican's report and face sheet listed allergy to fish that results in nausea and vomiting. Interview's with staff revealed that the soup came from the facilities kitchen. Assistant Administrator reported that the topic of resident food allergies and labeling food delivered from the kitchen was discussed during a staff meeting. Facility also reported that resident allergy information is posted in the kitchen and in every house in the facility. LPA observed allergy information postings in the facility.

Deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plan of Correction was jointly developed with the Sano. An exit interview was conducted with Sano, 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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alyssa RamirezTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024
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 06/04/2024 02:28 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: ST. PAUL'S PLAZA
FACILITY NUMBER: 374603643

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2024
Section Cited
HSC
87555(b)(7)

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Food Service Modified diets prescribed by a resident's physician as a medical necessity shall be provided.
This requirement was not met as evidence by: Based on interview and records review the licensee did not comply with the section cited above
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Administrator will ensure that staff are trained on food allergies by POC due date. Administrator will send LPA sign in sheet from training by POC due date.
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 in one (R1) out of 141 resident’s due to staff inadvertently giving R1 an ingredient in which R1 is allergic. This inspected which poses a potential health, safety or personal rights risk to persons in care. This poses an immediate risk to resident in care.

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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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alyssa RamirezTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024
LIC809 (FAS) - (06/04)
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