370804484-4-15-2024-08-AS-CLOZ-D4D3ZP-20240415184151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370804484
Report Date: 04/15/2024
Date Signed: 04/15/2024 06:42:07 PM

Document Has Been Signed on 04/15/2024 06:42 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. JOSEPH'S GUEST HOME		FACILITY NUMBER:	370804484
ADMINISTRATOR/ DIRECTOR:	ANGELITA SANCHEZ		FACILITY TYPE:	740
ADDRESS:	1576 CASTEEL COURT		TELEPHONE:	(619) 267-5909
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92114
CAPACITY: 5		CENSUS: 3	DATE:	04/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Teofila Mayo, Administrator		TIME VISIT/ INSPECTION COMPLETED:	06:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by Administrator Teofila Mayo, Administrator. LPA discussed the purpose of the visit with Administrator Mayo. Assistant Administrator Vanessa Sanchez later arrived and joined the visit. According to the facility’s license, there may be a maximum of five (5) residents, four (4) of whom may be non-ambulatory in rooms 1, 2, and 4; and wheelchair approved in room 4 in at any given time at the facility site. The facility is approved for one (1) hospice resident. During today’s inspection, the facility’s current census is three (3) residents living at the facility. There were 3 residents present at the facility site during the inspection. LPA, accompanied by Administrator Mayo, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities. The facility’s ambient internal temperature was comfortable and compliant, at 74 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were also compliant: kitchen sink measured hot water temperature at 116.4 degrees F; sink in restroom #1 delivered hot water at 118.8 degrees F; and sink in restroom #2 delivered hot water at 112.6 degrees F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present, and all safely stored. There were no toxic chemicals/poisons accessible to residents. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 9

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. JOSEPH'S GUEST HOME	FACILITY NUMBER: 370804484
	VISIT DATE: 04/15/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

Medications were properly labeled, as required, and stored in locked cabinet which LPA inspected. LPA reviewed resident medications which LPA discovered that one residents medication was not provided to resident as prescribed. LPA went over Incidental Medical and Dental Care with the Administrator Mayo and Assistant Administrator Sanchez.

No pools or bodies of water on the premises. Per Assistant Administrator Sanchez, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was present (01) and serviced within the last 12 months. First aid kit(s) were complete and readily accessible.

LPA interviewed staff and resident, and reviewed staff and residents’ records. During today’s visit there were 3 residents on the facility premise. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained most required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

There were deficiencies observed and cited during today's annual inspection and may be reviewed on the LIC-809D page of this report.

An exit interview was conducted and a plan of correction was jointly developed with Assistant Administrator Sanchez to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Assistant Administrator Sanchez to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, and Emergency Disaster Plan LIC 610-E to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

LIC809 (FAS) - (06/04)

Page: 2 of 9

Document Has Been Signed on 04/15/2024 06:42 PM - It Cannot Be Edited

Created By: Carmen Lopez On 04/15/2024 at 05:28 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
, 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: 04/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above in 2 out of 3 residents did not have their Physician's Report updated within the last year which posed a potential health risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Facility will be obtaining residents Physician's Report and submitting to LPA by POC due date, 05/01/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jennifer Lott

LICENSING EVALUATOR NAME:

Carmen Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

LIC809 (FAS) - (06/04)

Page: 3 of 9

Document Has Been Signed on 04/15/2024 06:42 PM - It Cannot Be Edited

Created By: Carmen Lopez On 04/15/2024 at 05:28 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
, 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: 04/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(5)(A)

Medications usually prescribed for self-administration which have been authorized by the person's physician. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 3 resident's were not provided medication as prescribed which posed an immediate health risk to person in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Facility will submit an incident report to the Department to indicate the reporting requirements and steps taken before, during and after the incident by 4/16/24. Facility will also ensure that the staff conduct medication training by a third-party agency by .

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jennifer Lott

LICENSING EVALUATOR NAME:

Carmen Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

LIC809 (FAS) - (06/04)

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