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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370804484
Report Date: 07/22/2021
Date Signed: 07/22/2021 03:37:31 PM

Document Has Been Signed on 07/22/2021 03:37 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ST. JOSEPH'S GUEST HOMEFACILITY NUMBER:
370804484
ADMINISTRATOR:ANGELITA SANCHEZFACILITY TYPE:
740
ADDRESS:1576 CASTEEL COURTTELEPHONE:
(619) 267-5909
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 5CENSUS: 3DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee/Administrator, Angelita SanchezTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lizzette Tellez visited the facility to conduct an annual required licensing inspection. LPA was met by Staff, Liz Lorezco, and was granted entry into the facility. LPA met with Ms. Lorezco and discussed the purpose of the visit. Licensee/Administrator, Angelita Sanchez, arrived during the visit.

During today's visit, LPA toured the facility, and verified compliance with infection control practices. LPA and Ms. Sanchez reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report. LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of cleaning products and PPE.

During the visit, the facility's sole fire extinguisher was found not charged and inoperable. An immediate civil penalty for a Fire Safety violation was issued in the amount of $500.00.

A deficiency was cited in accordance with the California Code of Regulation, Title 22, and is noted on the attached 809-D. An exit interview was conducted with Ms. Sanchez, and a copy of this report, along with a Civil Penalty Assessment Form, and Licensee Rights (LIC 9058 FAS 01/16) were provided to them via email. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Lizzette Tellez
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2021
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 07/22/2021 03:37 PM - It Cannot Be Edited


Created By: Lizzette Tellez On 07/22/2021 at 11:17 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ST. JOSEPH'S GUEST HOME
FACILITY NUMBER: 370804484

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
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 is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above when the sole fire extinguisher was found to be inoperable, which poses an immediate safety risk to persons in care.
POC Due Date: 07/23/2021
Plan of Correction
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Licensee stated an operable fire extinguisher would be purchased and maintained in the facility. Licensee stated proof of purchase would be provided to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:John Rante
LICENSING EVALUATOR NAME:Lizzette Tellez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021


LIC809 (FAS) - (06/04)
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