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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602061
Report Date: 02/20/2024
Date Signed: 02/20/2024 04:19:03 PM

Document Has Been Signed on 02/20/2024 04:19 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:DEL CERRO MANORFACILITY NUMBER:
374602061
ADMINISTRATOR:BENJAMIN D. BARTHFACILITY TYPE:
740
ADDRESS:6667 WANDERMERE CTTELEPHONE:
(619) 741-5232
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY: 6CENSUS: 4DATE:
02/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elda Acosta, Facility ManagerTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility background information was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by caregiver Lorena Banuelos Castillo. LPA discussed the purpose of the visit with caregiver Blanca Garcia. Facility Manager Elda Acosta later arrived and joined the visit.

According to the facility’s license, there may be a maximum of six (6) residents all of whom may be non-ambulatory in at any given time at the facility site. They may have one (1) bedridden resident in bedroom #2 and the facility is approved for a hospice waiver for 1 resident. During today’s inspection, the facility’s current census is 4 residents living at the facility. There were 4 residents present at the facility site during the inspection.


LPA, accompanied by caregiver Garcia and facility manager Acosta, toured the interior and exterior sections of the facility, and inspected each room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, 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 activities.

The facility’s ambient internal temperature was comfortable and compliant, at 76 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were also compliant: kitchen sink delivered hot water at 120 degrees F; sink in restroom #1 delivered hot water at 105.1 degrees F; and sink in restroom #2 delivered hot water at 105.1 degrees F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present and stored. Sharps were not safely stored in a locked or inaccessible area but facility manager placed a lock on the cabinet door during the inspection. There were no toxic chemicals or poisons accessible to residents. LPA found that medications were properly labeled, as required, and stored in a locked area. The facility maintained medication logs which LPA reviewed.

[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2024
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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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: DEL CERRO MANOR
FACILITY NUMBER: 374602061
VISIT DATE: 02/20/2024
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[CONTINUED FROM LIC 809]

No pools or bodies of water on the facility premises. Per facility manager Elda Acosta, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present (01) and serviced within the last 12 months. First aid kit(s) were readily accessible.

LPA interviewed staff and residents, and reviewed staff and resident records. During today’s visit there were 4 residents on the facility premise. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

There were deficiencies observed and cited during today's annual inspection and may be found on the LIC809-D page of this report along with the Technical Advisory's.

An exit interview was conducted with facility manager Elda Acosta to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.


LPA requested facility manager Acosta to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, Emergency Disaster Plan LIC 610-E, and Residential Infection Control Plan LIC 9282 (6/23), to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/20/2024 04:19 PM - It Cannot Be Edited


Created By: Carmen Lopez On 02/20/2024 at 02:08 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: DEL CERRO MANOR

FACILITY NUMBER: 374602061

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 4 persons [R1] did not have an approved waiver for a full bedrail which posed a potential personal rights risk to 1 of 4 persons in care.
POC Due Date: 03/06/2024
Plan of Correction
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The facility will be submitting an exception for R1 to be approved for the full bedrail by POC due date, 03/06/2024.
Type B
Section Cited
CCR
87705(f)(1)

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that sharps were in an accessible cabinet to persons which posed a potential safety risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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This deficiency was cleared during the inspection as the facility obtained a lock to lock the cabinet that contained the sharps.
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:Carmen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024


LIC809 (FAS) - (06/04)
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