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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601097
Report Date: 07/03/2023
Date Signed: 07/03/2023 02:03:00 PM

Document Has Been Signed on 07/03/2023 02:03 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 DEL SOLFACILITY NUMBER:
374601097
ADMINISTRATOR:VIDA DACANAYFACILITY TYPE:
740
ADDRESS:4290 LAYLA WAYTELEPHONE:
(619) 662-1979
CITY:SAN DIEGOSTATE: CAZIP CODE:
92154
CAPACITY: 6CENSUS: 5DATE:
07/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver Priscilla "Lily" Dacanay and Administrator's Assistant Edgar DacanayTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Priscilla “Lily” Dacanay. LPA then met with the administrator's assistant, Edgar Dacanay, who arrived later during the visit.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 04/10/2023). According to the LIC624: on 04/08/2023, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of person identifiers used in this report.] Staff immediately notified law enforcement, who located and returned R1 to the facility unharmed/uninjured.

As of CCLD’s 07/03/2023 site visit, R1 had since moved out of the facility and was not present. During today’s visit, LPA performed a facility tour and welfare check on the remaining residents, finding no immediate safety concerns. LPA also reviewed resident care records and interviewed relevant facility staff.

According to their latest LIC602 Physician’s Report (dated 03/10/2023): R1 was diagnosed with Schizophrenia and Dementia, and their doctor determined that they were not able to safely leave the facility unassisted.

Multiple staff interviews corroborated: On the date of the incident, R1 was initially exercising/walking around the facility’s front and back yards, but still remained on the facility premises. Staff visually checked on R1 regularly. Upon first observing that R1 had walked off-property, staff timely phoned law enforcement, R1’s “emergency contact” person, R1’s case worker, and CCLD. While law enforcement searched for R1, facility staff also drove around the adjacent neighborhoods to search for them. Law enforcement located R1 around 1.5 hours later at a nearby park and returned them to the facility unharmed/uninjured. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2023
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 DEL SOL
FACILITY NUMBER: 374601097
VISIT DATE: 07/03/2023
NARRATIVE
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[CONTINUED FROM LIC 809] R1 had exercised on prior occasions in the facility’s yards, without safety problems. A preponderance of evidence does not exist to show that licensee did not provide needed observation to R1, or that licensee did not meet reporting requirements. No deficiencies were cited for the incident itself.

However, during today’s record review (and corroborated by staff, LPA observed that: a) Licensee did not possess an Absentee Notification Plan for R1, Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), Resident #5 (R5), or Resident #6 (R6), as was required; b) Licensee did not possess evidence of receipt of resident’s Personal Rights by R1, R2, R3, R4, R5, or R6, as was required; and, c) Licensee did not possess an initial personal property inventory for R1, R2, R3, R4, R5, or R6, as was required. Additionally, d) Licensee did not possess a completed LIC602 Physician’s Report (or equivalent medical assessment) for R3, R4, and R5; and e) R6, who was diagnosed with Dementia per medical records, did not have an LIC602 Physician’s Report (or equivalent medical assessment) completed/updated within the last year, as was required.

Deficiencies were cited per California Code of Regulations, Title 22, and California Health and Safety Code (refer to the attached LIC 809-D). Plans of Correction were jointly developed with the licensee. LPA also provided Technical Assistance to Licensee regarding staff auditory and/or alert devices on exit doors.

An exit interview was conducted with Edgar Dacanay, to whom a copy of this report, the LIC809-D pages, the LIC9012-TA page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/03/2023 02:03 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/03/2023 at 12:40 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: CASA DEL SOL
FACILITY NUMBER: 374601097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2023
Section Cited
HSC
1569.317

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1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall, for the purpose of addressing issues that arise when a resident is missing from the facility, develop and comply with an absentee notification plan…”
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Licensee agreed to write an Absentee Notification Plan (meeting the requirements of Heath and Safety Code Section 1569.317), and to place a copy of it in the resident files of R2, R3, R4, R5, and R6, respectively. Licensee agreed to train its current direct care staff on this Absentee Notification Plan. Licensee agreed to E-mail LPA a copy of the Absentee Notification Plan, and the training sign-in sheet, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, licensee did not develop an absentee notification plan for 6 of 6 residents (R1, R2, R3, R4, R5, and R6), which posed a potential safety risk to persons in care.
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Type B
08/02/2023
Section Cited
CCR87458(a)

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87458 Medical Assessment: “(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.”
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Licensee agreed to coordinate with physicians, responsible parties, and/or case managers, as needed, to obtain a completed and signed LIC602 Physician’s Reports for R3, R4, and R5, and to place them in their respective resident files. Licensee agreed to update its internal admission policies/procedures to make this document a pre-requisite for move in. Licensee agreed to E-mail LPA a copy of the LIC602’s for R3, R4, and R5, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, for 4 of 6 residents (R1, R3, R4, and R5), prior to their acceptance as a resident, licensee did not obtain and keep on file, documentation of a medical assessment, signed by a physician, which posed a potential health, safety, and personal rights 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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2023 02:03 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/03/2023 at 12:49 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: CASA DEL SOL
FACILITY NUMBER: 374601097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2023
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia: “(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.”
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Licensee agreed to coordinate with R6’s physician, responsible party, and/or case manager, as needed, to obtain a new/updated LIC602 Physician’s Report for R6, and to place in R6’s resident file. Licensee agreed to mark their internal calendar to remind them that for every resident diagnosed with dementia, Licensee will need to facilitate a new LIC602 within the next 12 months. Licensee agreed to E-mail LPA a copy of R6’s new/updated LIC602, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, licensee did not ensure that 1 of 6 residents (R6), who was diagnosed with dementia, had a medical assessment performed within the last year, which posed a potential health, safety, and personal rights risk to persons in care.
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Type B
08/02/2023
Section Cited
CCR87468(b)(1)(A)

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87468 Personal Rights: “(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1…and 87468.2…(A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.”
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Licensee agreed to coordinate with residents and/or responsible parties (where applicable), to complete signed LIC613C forms (“Personal Rights of Residents in Privately Operated Residential Care Facilities for the Elderly”) for R2, R3, R4, R5, and R6, and to place them in their respective resident files. Licensee agreed to update its internal admission policies/procedures to ensure the LIC613C is completed at or before time of move-in. Licensee agreed to E-mail LPA a copy of the LIC613C signature pages for R2, R3, R4, R5, and R6, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, for 6 of 6 residents (R1, R2, R3, R4, R5, and R6), Licensee did not ensure that a signed copy of the resident rights was included in the residents’ records, which posed a potential personal rights 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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2023 02:03 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/03/2023 at 01:14 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: CASA DEL SOL
FACILITY NUMBER: 374601097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2023
Section Cited
CCR
87218(a)(1)

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87218 Theft and Loss: “(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative.”
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Licensee agreed to coordinate with residents and/or responsible parties (where applicable), to complete LIC621 forms (“Client/Resident Personal Property and Valuables”) for R2, R3, R4, R5, and R6, and to place them in their respective resident files. Licensee agreed to update its internal admission policies/procedures to ensure the LIC621 is completed at or before time of move-in. Licensee agreed to E-mail LPA a copy of the signed LIC621s for R2, R3, R4, R5, and R6, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, for 6 of 6 residents (R1, R2, R3, R4, R5, and R6), Licensee did not maintain a personal property inventory, completed by the licensee and the resident and/or their representative, which posed a potential personal rights 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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023


LIC809 (FAS) - (06/04)
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