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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370800558
Report Date: 10/23/2024
Date Signed: 10/23/2024 04:16:58 PM

Document Has Been Signed on 10/23/2024 04:16 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:ST PAUL'S MANORFACILITY NUMBER:
370800558
ADMINISTRATOR/
DIRECTOR:		DAMIEN RAPPFACILITY TYPE:
740
ADDRESS:2635 SECOND AVETELEPHONE:
(619) 239-2097
CITY:SAN DIEGOSTATE: CAZIP CODE:
92103
CAPACITY: 200CENSUS: 97DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Carol Braun Resident Services CoordinatorTIME VISIT/
INSPECTION COMPLETED:
12:24 PM
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Licensing Program Analyst (LPA) Amy Domingo, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Domingo was granted entry into the facility by Resident Services Coordinator, Carol Braun, after identifying herself and stating the purpose of the inspection.

The facility serves two hundred (200) elderly residents age sixty (60) and above; six (6) of whom may be non-ambulatory and may use rooms #101- #106. There is an approved hospice waiver for three (3) residents. This is a four story complex, with no delayed egress and secured perimeters.

LPA was accompanied by Resident Service Coordinator Carol Braun during a tour of the facility. The tour was conducted within the interior and exterior and included a sample of resident units, the dining area, recreation rooms, and food storage areas. Signal systems are in place and operational. No bodies of water are on premises. Passageways were free from obstructions. According to executive director, there are no weapons and/or ammunition stored on the premises. Call box was available in each resident unit and were tested for functionality. Resident's room temperatures were within a comfortable 72 degree F range.

Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are all accessible in rooms or in locked hall closet.  All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant.

[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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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: ST PAUL'S MANOR
FACILITY NUMBER: 370800558
VISIT DATE: 10/23/2024
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[CONTINUED FROM LIC 809]

Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked cabinet. Clients are independent and do not require medication management.

Resident records reviewed for a current Physician's Report, Resident Appraisal, Needs & Services Plan, Identification and Emergency Information, and Admission Agreement. Administrator’s certification is current. Transportation procedures were reviewed and complaint. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

LPA interviewed staff and he interview did not raise any significant licensing concerns.  LPA reviewed records/files.  Staff are current on training requirements. Client files contained required documents.   Confidential records were stored in locked areas.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted, this report was discussed with Carol Braun, Resident Services Coordinator, and a copy along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to Carol Braun, Resident Services Coordinator.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
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