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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600996
Report Date: 09/19/2025
Date Signed: 09/19/2025 05:37:25 PM

Document Has Been Signed on 09/19/2025 05:37 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:VELASCO HOMES #5, THEFACILITY NUMBER:
374600996
ADMINISTRATOR/
DIRECTOR:		SANFORD, LAILANI JOYFACILITY TYPE:
740
ADDRESS:1564 MALTA AVENUETELEPHONE:
(619) 476-7011
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 6DATE:
09/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:House Manager Flavel CatahanTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen made an unannounced visit to conduct a Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with House Manager Flavel Catahan. LPA also spoke briefly via phone with Administrator Lailani Velasco.

According to the facility’s license, the facility has a maximum capacity for six (6) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of six (6) residents in care, of whom two (2) were ambulatory and four (4) were non-ambulatory, but none were bedridden. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter doors, and neither of these were present.

LPA, accompanied by Licensee’s staff, toured the interior and exterior of the facility and inspected all common areas and resident bedrooms. LPA met with multiple residents and interviewed all staff who were present. LPA reviewed care records for all residents and personnel records for all active staff.

During the facility tour, LPA observed: In the facility’s kitchen were eight (8) sharp cooking and/or steak knives unlocked/unsecured. Of these, one (1) had a metal blade over ten inches long, and seven (7) had a metal blade over six inches long. Per facility records, 6 of 6 residents in care [Resident #1 (R1) through Resident #6 (R6)] were diagnosed with significant intellectual disabilities. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] Regulation thus required these knives to be kept in “locked storage” when not in active use by staff. In 4 of 4 bathrooms used by residents, the showers did not have “slip resistant mats, strips, or flooring,” as required. [CONTINUED ON LIC809-C, 1 of 2]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2025
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 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: VELASCO HOMES #5, THE
FACILITY NUMBER: 374600996
VISIT DATE: 09/19/2025
NARRATIVE
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[CONTINUED FROM LIC 809]

Beyond the above, the facility was clean, sanitary, and in good repair. Pathways were free of obstruction and trip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 74 F. Where tested, hot water temperature at taps accessible to residents were all compliant: Kitchen Sink was 107.2 F, Bathroom #1 Sink was 115.7 F, Bathroom #2 Sink was 111.7 F, Bathroom #3 Sink was 117 F, and Bathroom #4 Sink was 115.2 F. Appliances to preserve perishable food were also compliant in temperature. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present.

There were no toxic chemicals/poisons, open-faced heaters, or other hazardous items accessible to residents. Medications were labeled, as required, and stored in locked areas. Carbon monoxide detector, smoke detectors, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguisher had been serviced within the last twelve (12) months. No fireplaces or pools/bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Required licensing postings were observed in visible areas of the facility. Licensee presented proof of current business liability insurance and surety bond.

During review of resident records, LPA observed, and staff interview confirmed: Licensee did not have a copy of a signed Admissions Agreement contract on file for R1, who records show moved into the facility in May 2025. Records showed R2 relocated to this facility in February 2023 from one of Licensee’s other facilities. However, Licensee did not sign a new Admissions Agreement contract with R2 for The Velasco Homes #5, as required. (CCLD considers each facility to be a legally distinct from the other,) For 3 of 6 residents (R2, R3, and R4), Licensee did not maintain a written Absentee Notification Plan as part of their written record of care, as required.

[CONTINUED ON LIC 809-C, 2 of 2]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
LIC809 (FAS) - (06/04)
Page: 3 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: VELASCO HOMES #5, THE
FACILITY NUMBER: 374600996
VISIT DATE: 09/19/2025
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

During review of personnel and training records, LPA observed, and staff interview confirmed: Licensee did not maintain at the facility a complete personnel file on themselves, as required. For 7 of 7 direct care staff [Staff #1 (S1) through Staff #7 (S7)], Licensee did not ensure these persons received at least twenty (20) hours of training annually. [Regulation requires at least twenty (20) hours of continuing education/training per year, of which of which eight (8) hours must be on Dementia, and four (4) hours must be on Restricted Health Conditions, Hospice Care, and Postural Supports.] Licensee also did not ensure that 8 of 9 staff [S1 through Staff #8 (S8) had been trained on either Personal Protective Equipment (PPE) or the facility’s written LIC610 Emergency Disaster Plan within the last year, as required.

Five (5) deficiencies were cited per California Code of Regulations, Title 22, and three (3) deficiencies were cited per California Health and Safety Code (refer to the LIC809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued two (2) Technical Violations (TV), regarding frequency and variety of disaster drills and regarding knob protectors for the kitchen range (refer to the LIC9102-TV pages).

An exit interview was conducted with House Manager Flavel Catahan, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV pages, the LIC811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit. An electronic set of these same documents was E-mailed to the facility administrator.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 09/19/2025 05:37 PM - It Cannot Be Edited


Created By: Dang Nguyen On 09/19/2025 at 04:13 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: VELASCO HOMES #5, THE
FACILITY NUMBER: 374600996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, Licensee did not ensure that knives which could pose a danger to residents, were in locked storage and not left unattended. This posed an immediate health and safety risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 09/19/2025
Plan of Correction
1
2
3
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During today's visit, LPA handed the knives to staff to be relocated to locked cabinets. This resolved the immediate risk. Licensee agreed to retrain all current staff on what items constitute hazards and on their correct storage, and to E-mail the training sign-in sheet to LPA by 10/19/2025. (This class may count towards the staffs' 20 hours of required annual training.)
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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 09/19/2025 05:37 PM - It Cannot Be Edited


Created By: Dang Nguyen On 09/19/2025 at 04:13 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: VELASCO HOMES #5, THE
FACILITY NUMBER: 374600996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(b)(2)(C)
Infection Control Requirements
(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around residents and annually thereafter.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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Based on records review and staff interview, Licensee did not ensure that 8 of 9 staff (S1 through S8) received training on the proper use of all required PPE within the last year. This posed a potential health risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 10/19/2025
Plan of Correction
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Licensee agreed to train all current staff on PPE. The training will include hands-on practice and will cover: a) handwashing, b) how and how often to disinfect commonly touched surfaces, c) how to correctly don and doff surgical masks, N-95 respirators, face shields, gowns, and gloves, d) how perform an N-95 seal check, and e) how to correctly set up a COVID-19 isolation bedroom. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date. (This class may count towards the staffs' 20 hours of required annual training.) Going forward, Licensee agreed to repeat this training at least annually.
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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Based on LPA observation, Licensee did not maintain slip-resistant mats on shower floors in 4 of 4 bathrooms. This posed a potential safety risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 10/19/2025
Plan of Correction
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Licensee agreed to purchase and install (4) non-slip shower mats to be used inside the showers themselves. (These mats may be hanged to dry when not in active use by/with a resident.) Licensee agreed to E-mail the purchase receipt to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 09/19/2025 05:37 PM - It Cannot Be Edited


Created By: Dang Nguyen On 09/19/2025 at 04:13 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: VELASCO HOMES #5, THE
FACILITY NUMBER: 374600996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and staff interview, Licensee did not maintain proof that 7 of 7 direct care staff (S1 through S7) received 20 hours of continuing training within the last year, of which 8 hours shall be on Dementia Care, and of which 4 hours shall be specific to postural supports, restricted health conditions, and hospice care. This posed a potential health and personal rights risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 10/19/2025
Plan of Correction
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2
3
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Licensee agreed to conduct and docuement in writing a total 20 hours of training for S1 thorugh S7, ensure at least 8 of the hours are on Dementia, and at least 4 of the hours are on a combination that includes postural supports, restricted health conditions, and hospice care. Licensee agreed to E-mail proof of training completion to LPA, by the POC due date.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and staff interview, for 2 of 6 residents (R1 and R2), Licensee did not maintain in their record a current Admissions Agreement contract. This posed a potential personal rights risk to persons in care.
POC Due Date: 10/19/2025
Plan of Correction
1
2
3
4
Licensee agreed to coordinate with the authorized representatives for R1 and R2 to have Admissions Agreements for The Velasco Homes #5 signed for both residents. Licensee agreed to E-mail copies of R1 and R2's contracts to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 09/19/2025 05:37 PM - It Cannot Be Edited


Created By: Dang Nguyen On 09/19/2025 at 04:13 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: VELASCO HOMES #5, THE
FACILITY NUMBER: 374600996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(b)
Other Provisions
(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and staff interview, Licensee did not provide training to 8 of 9 staff members (S1 through S8) on the facility's written emergency and disaster plan within the last year. This posed a potential safety risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 10/19/2025
Plan of Correction
1
2
3
4
Licensee agreed to train all current staff on its existing LIC610D Emergency Disaster Plan, to include their responsibilities under it. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date. (This class may count towards the staffs' 20 hours of required annual training.) Going forward, Licensee agreed to repeat this training at least annually.
Type B
Section Cited
CCR
87412(a)
87412 Personnel Records: “(a) The licensee shall ensure that personnel records are maintained on the licensee…” This requirement was not met, as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and staff interview, Licensee did not ensure a complete personnel file was maintained on themselves at the facility. This posed a potential health risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 10/19/2025
Plan of Correction
1
2
3
4
Licensee agreed to gather copies of the following documents on themselves (S9), and add them to their personnel file at the facility: LIC501 Personnel Record, LIC508 Criminal Record Statement, LIC503 Health Screening with negative Tuberculosis test result, government-issued photo ID. Licensee also agreed to E-mail copies of the same to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 09/19/2025 05:37 PM - It Cannot Be Edited


Created By: Dang Nguyen On 09/19/2025 at 04:54 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: VELASCO HOMES #5, THE
FACILITY NUMBER: 374600996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.317
1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall…develop and comply with an absentee notification plan…The plan shall include…a requirement that an administrator of the facility, or his or her designee, inform the resident’s authorized representative when that resident is missing from the facility…and the circumstances in which [they] shall notify local law enforcement.” This requirement was not met, as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and staff interview, Licensee did not develop an absentee notification plan for 3 of 6 residents (R2, R3, and R4), which posed a potential safety risk to persons in care.
POC Due Date: 10/19/2025
Plan of Correction
1
2
3
4
Licensee agreed to write an Absentee Notification Plan/policy meeting the requirements of CA H&S Code 1569.317 for R2, R3, and R4, and maintain a copy of such in each client’s care file. Licensee agreed to E-mail copies of the Absentee Notification Plan for R2, R3, and R4 to LPA, by the POC due date.
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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2025


LIC809 (FAS) - (06/04)
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