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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202752
Report Date: 06/04/2022
Date Signed: 06/06/2022 09:41:08 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/06/2022 09:41 AM - 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,
, CA
FACILITY NAME:MESSINGER CARE HOMEFACILITY NUMBER:
275202752
ADMINISTRATOR:ESTAMO, JUANITO JRFACILITY TYPE:
740
ADDRESS:3121 MESSINGER DRTELEPHONE:
(831) 883-9386
CITY:MARINASTATE: CAZIP CODE:
93933
CAPACITY: 6CENSUS: 6DATE:
06/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Cristy BungayTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual/random visit on this date. LPA met with Cristy B. and Elisa Cruz (Staff). Administrator joined the inspection via telephone.

LPA inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in/or around the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 123.5 degrees Fahrenheit in resident bathroom sink, which is not within the required range of 105 to 120 degrees. Fire extinguishers was last serviced on 2/10/2020. Smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor presents. LPA was unable to determine when the last fire or disaster drill was conducted.

LPA observed centrally stored medications unlocked in a cabinet inside the office area (photo taken). LPA reviewed and compared resident medication vs. resident medication logs. During the medication review LPA observed medications for R1 and R2 empty with not replacements in the facility for prescribed medications. The last entry into the medication administration record was 6/2/2022. LPA reviewed 6 resident and 2 staff files, including criminal record clearances. All staff today are not associated to the facility. S1 is not associated to this facility. First aid kit was checked and is complete.

Per California Code of Regulations, Title 22 Division 6, Chapter 8 and Health and Safety Code, deficiencies were observed and cited during this visit. Exit interview held and a report given at the conclusion of the visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2022
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 06/06/2022 09:41 AM - It Cannot Be Edited


Created By: Albert Johnson On 06/04/2022 at 02:54 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
,
, CA

FACILITY NAME: MESSINGER CARE HOME
FACILITY NUMBER: 275202752

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2022
Section Cited
CCR
87203

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement was not met as evidenced by: Based LPA observation
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The Licensee/Administrator will send a plan of how and when the fire drill when be conducted as well as and having the fire extingushier serviced by the POC date
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LPA observed the fire extingushier not serviced and no record of a fire drill. This poses an immediate health and safety risk to resident in care.
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Type A
06/05/2022
Section Cited
CCR80088(e)(1)

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Furniture, Fixtures, Equipment, and Supplies
1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C)....
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Administrator shal lowered the thermostat and test the hot water for 3 days. Test hot water in the bathroom to meet Title 22 regulations. Send 3 day hot water temperature to LPA.
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LPA tested hot water at 123.5 degrees F. Licensee failed to assure hot water meeting Title 22 regulation of 105-120 degree F. This poses a potential health and safety 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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/06/2022 09:41 AM - It Cannot Be Edited


Created By: Albert Johnson On 06/04/2022 at 03:38 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
,
, CA

FACILITY NAME: MESSINGER CARE HOME
FACILITY NUMBER: 275202752

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2022
Section Cited
CCR
87355(e)(1)

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87355(e)(1)Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption. This requirement is not met as evidenced by:
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Licensee will immediately ensure (S1) is finger print cleared and associated to facility prior to reporting to work. Proof of clearance and association shall be submitted to CCL prior to resuming duties.
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interviews and records reviewed, S1 is not associated to this facility. This poses and immediate health and safety risk to residents.
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Administrator shall submit a Statement of Understanding regarding the requirements by POC date via email to CCL.IMMEDIATE CIVIL PENALTY ASSESSED
Type B
06/17/2022
Section Cited
CCR87465(c)(2)

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87465(c)(2) Incidental Medical and Dental Care Services. Once ordered by the physician, nonprescription PRN medications shall be given in accordance with the physician’s directions. LPA observed that Resident 1
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Admin. will provide in-service training to staff in regards to 87465 Incidental Medical and Dental Care/medication recordkeeping and send copy via email to LPA Johnson by POC date 6/17/2022
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 (see LIC 811) was out of Hydroxyzine and R2 was out of Citracal (needs daily). This is a potential 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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2022


LIC809 (FAS) - (06/04)
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