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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601302
Report Date: 10/28/2024
Date Signed: 10/28/2024 04:12:10 PM

Document Has Been Signed on 10/28/2024 04:12 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:MISSION HOME IIIFACILITY NUMBER:
374601302
ADMINISTRATOR/
DIRECTOR:
CURMAK, CERENFACILITY TYPE:
740
ADDRESS:2493 MELBOURNE DRIVETELEPHONE:
(858) 560-7676
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY: 6CENSUS: 6DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Caregiver Maria Barragan and Adminstrator Ceren CurmakTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hannah Rodgers, LPA Juliana Barfield, and Licensing Program Manager (LPM) Lizzette Tellez conducted an unannounced Required Annual Inspection.The facility file was reviewed prior to the visit.  LPAs and LPM were welcomed by and discussed the purpose of the visit to Caregiver Maria Barragan. Administrator Curmak arrived during the visit. The facility's license shows a maximum capacity of 6 non-ambulatory residents. During today’s inspection there were 6 residents in care.

LPAs and LPM accompanied by Barragan toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings.  Doors, windows, screens, toilets, and showers were in working order.  Extra linens and hygiene supplies were present, as well as Personal Protective Equipment.  The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored.  Cooking, dining equipment, and utensils were present.  No toxic chemicals or poisons were accessible to residents.  Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Barragan, no firearms or ammunition are kept at the facility.  Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher was serviced within the last 12 months.  First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPAs interviewed staff and residents, and reviewed facility records. During review of resident records LPAs observed that Resident #1 (R1), a resident with a major neurocognitive disorder, did not have an updated medical assessment and reappraisal. Confidential records were stored in locked areas.  

A deficiency was cited in accordance with CCR Title 22. An exit interview was conducted with Barragan to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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Document Has Been Signed on 10/28/2024 04:12 PM - It Cannot Be Edited


Created By: Hannah Rodgers On 10/28/2024 at 03:41 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: MISSION HOME III

FACILITY NUMBER: 374601302

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)


This requirement is not met as evidenced by:
Each resident with dementia shall have an annual medical assesment as specified in section 87458, Medical Assesment, and a reappraisal done at least annualy both of which shall include a reassesment of the resident's dementia care needs.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 persons (R1) which posed a potential health and safety risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Licensee stated an updated medical assessment and reappraisal would be obtained for R1 and copies provided to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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