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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601035
Report Date: 01/10/2025
Date Signed: 01/10/2025 02:56:31 PM

Document Has Been Signed on 01/10/2025 02:56 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:LUCY'S PLACEFACILITY NUMBER:
374601035
ADMINISTRATOR/
DIRECTOR:		LUCIA B.TOTANESFACILITY TYPE:
740
ADDRESS:4770 ELM TREE DRIVETELEPHONE:
(760) 806-3873
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY: 6CENSUS: 2DATE:
01/10/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Caregiver Victoria DaoTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Case Management - Annual Continuation. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Victoria Dao.

The facility is licensed for a maximum capacity of 6 residents, 4 of which may be non-ambulatory. The facility has a waiver for 4 hospice residents. During today’s visit, the facility had a census of 2 non-ambulatory residents. The Administrator for the facility is Lucia Totanes and their certificate was valid and current.

During visits on 12/6/2024 and 1/10/2025, LPA toured the facility and inspected each room of the facility, including resident and staff rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 115.2 and 118.2 degrees Fahrenheit in bathrooms for resident use. The facility’s internal temperature was measured at 70 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Victoria Dao, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 45 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate.

Continued on LIC809-C page…
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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 4
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: LUCY'S PLACE
FACILITY NUMBER: 374601035
VISIT DATE: 01/10/2025
NARRATIVE
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LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, initial physician’s report and appraisal assessment, documents regarding safeguarding personal property, and personal rights. Review of staff files revealed that Staff 1 and Staff 2 records were not complete and were not accessible to licensing personnel during the visit. [Dao was provided with an LIC811 Confidential Names List to identify S1 and S2]. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns. Review of facility records including plan of operation revealed that the facility did not have an infection control plan or emergency disaster plan that was available for review.

The following deficiencies were cited for not having an Infection Control Plan, not having an Emergency Disaster Plan, and incomplete personnel records and noted on the attached LIC809-D pages.

An exit interview was conducted with Caregiver Victoria Dao, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/10/2025 02:56 PM - It Cannot Be Edited


Created By: Rebecca A Borunda On 01/10/2025 at 02:19 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: LUCY'S PLACE
FACILITY NUMBER: 374601035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that there is no Infection Control Plan document that is maintained at the facility for staff and licensing review. This poses a potential health risk to 2 of 2 residents in care.
POC Due Date: 02/09/2025
Plan of Correction
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2
3
4
Caregiver Dao stated that Licensee will create an Infection Control Plan. Licensee will notify the Department that the Infection Control Plan document is completed by the POC due date of 2/9/2025.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in that personnel records for S1 and S2 were not complete or available for licensing review which poses a potential safety risk to 2 of 2 residents in care.
POC Due Date: 02/09/2025
Plan of Correction
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Caregiver Dao stated that Licensee will update personnel records for S1 and S2. Licensee will notify the Department that the personnel records for S1 and S2 are complete and maintained at the facility by POC due date of 2/9/2025.
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:Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/10/2025 02:56 PM - It Cannot Be Edited


Created By: Rebecca A Borunda On 01/10/2025 at 02:19 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: LUCY'S PLACE
FACILITY NUMBER: 374601035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that there is no Emergency and Disaster Plan document that is maintained at the facility for staff and licensing review. This poses a potential safety risk to 2 of 2 residents in care.
POC Due Date: 02/09/2025
Plan of Correction
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3
4
Caregiver Dao stated that Licensee will create an Emergency and Diaster Plan. Licensee will notify the Department that the Emergency and Diaster Plan document is completed by the POC due date of 2/9/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2025


LIC809 (FAS) - (06/04)
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