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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881347
Report Date: 08/21/2024
Date Signed: 08/21/2024 03:00:22 PM

Document Has Been Signed on 08/21/2024 03:00 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KELLY'S ALMAGRO VILLAFACILITY NUMBER:
371881347
ADMINISTRATOR/
DIRECTOR:		WELKER, KELLYFACILITY TYPE:
740
ADDRESS:1889 ALMAGRO LANETELEPHONE:
(619) 504-5049
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 5DATE:
08/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Caregiver, Leila TobiasTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 8/21/2024, Licensing Program Analyst (LPA) Janette Romero arrived unannounced case management visit to follow up on an exception request submitted for Resident 1 (R1). LPA met with Caregivers, Leila Tobias and Joanna Dizon who were informed of the purpose of the visit. Administrator, Kelly Welker was contacted over-the-phone and also informed of the purpose of LPA's visit.

In the review of documents submitted for R1, it was discovered there was contradictory information related to the ambulatory status of R1. LPA reviewed R1's Physician's Report (LIC602A) dated 6/17/2024 which indicates R1 is non-ambulatory but also unable to independently transfer to and from bed, and noted they are bed bound. The LIC602A states R1 is not receiving hospice services, which was corroborated by facility staff. LPA was informed R1 is receiving home health services at the facility twice per week. LPA reviewed R1's home health records dated 6/12/2024 stating R1 requires consistent repositioning every two (2) hours. R1 was interviewed and reported they are unable to reposition themselves. Per a Fire Safety Inspection Request (STD. 850) dated 6/30/2022, the facility has a fire clearance for six (6) non-ambulatory elderly residents. Based on the aforementioned, the facility is in violation of their approved fire clearance. An exit interview was conducted and this report was reviewed with Administrator Welker over-the-phone and in-person with Caregivers Tobias and Dizon. A copy of this report was provided to the Caregiver Tobias along with a Confidential Names List (LIC 811), LIC809-D and LIC421M.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
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 08/21/2024 03:00 PM - It Cannot Be Edited


Created By: Janette Romero On 08/21/2024 at 02:28 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KELLY'S ALMAGRO VILLA
FACILITY NUMBER: 371881347

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2024
Section Cited
CCR
87202(a)

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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal... This requirement was not met as evidenced by:
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Licensee reported they will contact their local fire department and report the facility has a bedridden resident. Licensee added R1 will be relocated to a facility with an appropriate fire clearance.
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Documents submitted for R1 provided contradictory information related to the ambulatory status of R1. R1 was interviewed and reported they are unable to reposition themselves. The facility is in violation of their fire clearance. This poses an immediate health/safety/personal rights risk to residents in care.
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Licensee stated POC to be submitted to LPA via email by close of business on 8/22/2024.

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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:Tricia Danielson
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024


LIC809 (FAS) - (06/04)
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