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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600980
Report Date: 04/28/2023
Date Signed: 04/28/2023 12:00:18 PM

Document Has Been Signed on 04/28/2023 12:00 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CASA DE CASTRO IIFACILITY NUMBER:
374600980
ADMINISTRATOR:CHERYL CASTROFACILITY TYPE:
740
ADDRESS:7766 PRAIRIE MOUND WAYTELEPHONE:
(619) 475-7525
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY: 6CENSUS: 6DATE:
04/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Cheryl Castro via telephoneTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted a case management visit to cite for deficiencies observed during a complaint investigation. LPA spoke with Cheryl Castro, via telephone, with whom she discussed the purpose of the visit.

During a complaint investigation, LPA discovered, through interviews, that Resident 1 (R1) [LIC 811 Confidential Names List was provided to identify the resident] was transported from the home by the Psychiatric Emergency Response Team following a behavioral incident that occurred on or about March 29, 2023. R1 was transported to a local hospital. Interviews revealed that, several hours later, the facility’s licensee was contacted by the hospital staff, and the licensee was asked whether R1 would be accepted back into the home once he/she was settled. At that time, the licensee informed hospital staff that R1 would not be accepted back into the home; no notice of eviction had been provided to the resident. Subsequently, R1 was admitted into the hospital and remained there until hospital staff found another place to which R1 could be discharged.

While conducting the same complaint investigation, during a review of records maintained by the facility, LPA discovered that licensee had been provided hospital records which reflect that prior to R1’s admission into the facility, which occurred on December 13, 2022, R1 was admitted into a local hospital on October 24, 2022, for dementia with behavioral disturbance. It is noted in the records that R1 was admitted on a 5150 (involuntary 72-hour psychiatric hospitalization) hold because R1 was determined to be a danger to others. It was also noted in hospital records that R1 would be evaluated for adjustment of psychotropic medications and to prevent immediate danger to self or others. The records reflect that R1 remained in the hospital until discharged to the facility on December 13, 2022. LPA reviewed the preplacement appraisal completed by licensee, dated December 13, 2022, and observed that the preplacement appraisal reflects that R1 has a diagnosis of dementia and is confused; however, the appraisal reflects no indication of behavioral disturbance or any type of psychiatric incident(s) or hospitalization(s) associated with R1 or in R1’s history.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CASA DE CASTRO II
FACILITY NUMBER: 374600980
VISIT DATE: 04/28/2023
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Additionally, while conducting the complaint investigation, during a visit to the facility conducted on April 11, 2023, LPA requested to review staff training records. A review of records present at the facility at the time of the visit reflected that the most recent dementia training received by Staff 1 (S1) and Staff 2 (S2) was on January 23 and 24 of 2018.

Based upon the foregoing, deficiencies are being cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations and are listed on an LIC 809-D.

An exit interview was conducted, and this report was discussed, via telephone, with Cheryl Castro. Copies of this report and Licensee/Appeal Rights (LIC 9058) were provided to staff at the conclusion of the visit, and Emelita Supnet's signature on this form acknowledges receipt of the rights and a copy of this report.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/28/2023 12:00 PM - It Cannot Be Edited


Created By: Dawn Segura On 04/28/2023 at 08:52 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: CASA DE CASTRO II
FACILITY NUMBER: 374600980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/26/2023
Section Cited
CCR
87224(a)

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Eviction Procedures. The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement was not met as evidenced by:
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Licensee offered to ensure that both administrators receive outside vendor training on proper eviction procedures in accordance with Title 22 regulations. Licensee agreed to provide proof of training to Community Care Licensing by the POC due date.
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Based on interview, the licensee did not issue 30 days written notice to R1, 1 of 6 residents in care, prior to eviction. This posed a potential personal rights violation to persons in care.
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Request Denied
Type B
05/26/2023
Section Cited
CCR87457(c)(1)

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Pre-Admission Appraisal – General. Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs…(1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's
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Licensee offered to ensure that both administrators receive outside vendor training on conducting thorough assessments and documenting appraisals in accordance with Title 22 regulations. Licensee agreed to provide proof of training to Community Care Licensing by the POC due date.
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functional capabilities, mental condition and an evaluation of social factors…This req’t was not met as evidenced by: Based on records review, the licensee did not include an evaluation of 1 of 6 residents’ (R1) mental condition in the pre-admission appraisal. This posed a potential safety risk to persons in care.
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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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dawn Segura
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/28/2023 12:00 PM - It Cannot Be Edited


Created By: Dawn Segura On 04/28/2023 at 09:18 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: CASA DE CASTRO II
FACILITY NUMBER: 374600980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/26/2023
Section Cited
CCR
87707(a)(2)

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Training Requirements. Direct care staff shall complete at least eight hours of in-service training on the subject of serving residents with dementia within 12 months of working in the facility and in each succeeding 12-month period. This requirement was not met, as evidenced by:
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Licensee agreed to ensure that all staff receive and complete dementia training, as required by Title 22 regulations, and to provide proof of training to Community Care Licensing by the POC due date.
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Based upon a review of records, licensee did not ensure that S1 and S2 had dementia training within the last 12-month period. This posed potential health and safety risks to persons in care.
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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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dawn Segura
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
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