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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006103
Report Date: 07/19/2024
Date Signed: 07/23/2024 10:22:08 AM

Document Has Been Signed on 07/23/2024 10:22 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
Lookup Error,
, CA
FACILITY NAME:CASA FRANCESCAFACILITY NUMBER:
306006103
ADMINISTRATOR/
DIRECTOR:
OLIVA, MARIZAFACILITY TYPE:
740
ADDRESS:2942 CALLE GRANDE VISTATELEPHONE:
(949) 240-6889
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY: 6CENSUS: 6DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Administrator Mariza OIivaTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The
facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the
purpose of the visit with Administrator Mariza Oliva. According to the facility’s license, the facility has a maximum capacity of six residents, of whom all may be non-ambulatory, one of which may be bedridden.

LPA toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Bathroom with double vanity had one sick out of order and the working sick faucet was loose and not easy to control. Administrator states plumber is scheduled to fix both issues.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications labeled and locked as required.

No pool or body of water was present. Water temperature was measured at 106 degrees F. Per Mariza, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit was complete.

Resident records reviewed contained required documentation. Staff records reviewed did not have current first aid training in three of three records or CPR training for any of staff.

Two deficiencies were cited on today's visit for First Aid/CPR training. One technical violation was issued for sinks and faucet. An exit interview was conducted with Administrator, to whom a copy of this report,(LIC9099-x2) and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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 07/23/2024 10:22 AM - It Cannot Be Edited


Created By: Iby Strong On 07/19/2024 at 09:22 AM
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: CASA FRANCESCA

FACILITY NUMBER: 306006103

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review the licensee did not comply with the section cited above in 3 of 3 staff (S1, S2, S3) which poses posed a potential health risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee agrees to have S1, S2 or S3 completed CRP training by due date and provide LPA proof via email.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review the licensee did not comply with the section cited above in 3 of 3 staff (S1, S2, S3) which poses posed a potential health risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee agrees to have S1, S2 AND S3 completed first aid training by due date and provide LPA proof via email.
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 Jacob
LICENSING EVALUATOR NAME:Iby Strong
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
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