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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601035
Report Date: 11/27/2023
Date Signed: 11/27/2023 11:36:19 AM

Document Has Been Signed on 11/27/2023 11:36 AM - 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:LUCY'S PLACEFACILITY NUMBER:
374601035
ADMINISTRATOR:LUCIA B.TOTANESFACILITY TYPE:
740
ADDRESS:4770 ELM TREE DRIVETELEPHONE:
(760) 806-3873
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY: 6CENSUS: 4DATE:
11/27/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Caregiver Victoria DaoTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Plan of Correction (POC) visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Caregiver Victoria Dao.

The purpose of today's visit was to verify if deficiencies cited on 11/8/2023 had been corrected. On 11/8/2023, the licensee was issued 2 deficiencies with a correction date of 11/22/2023. As of today's date, LPA Ruiz had not received any communication from the licensee requesting a POC extension date or correction documents.

During today's visit, LPA observed residents in care, centrally stored medications, and resident records. LPA observed resident medications which were centrally stored, locked, and stored in their original container. LPA spoke to Caregiver Victoria Dao who stated that the Licensee had attempted to arrange medication training for staff but was not successful. Therefore, deficiency 87465(h)(5) remains uncorrected as of today's date. An immediate civil penalty of $100 per day for a total of $500 is being assessed for failure to correct and will be ongoing until corrected.

Review of resident records revealed that they remained incomplete and were missing required documents, including admission agreements, preplacement appraisals, and needs and service documents. Therefore, deficiency 87506(a) remains uncorrected as of today's date. An immediate civil penalty of $100 per day for a total of $500 is being assessed for failure to correct and will be ongoing until corrected.

An exit interview was conducted with Caregiver Victoria Dao, whose signature below confirms receipt of a copy of this report, two LIC421FCs, and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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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