374602061-12-18-2025-08-AS-AROS-DPH286-20251218160945

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602061
Report Date: 12/18/2025
Date Signed: 12/18/2025 04:09:58 PM

Document Has Been Signed on 12/18/2025 04:09 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 MANOR		FACILITY NUMBER:	374602061
ADMINISTRATOR/ DIRECTOR:	BENJAMIN D. BARTH		FACILITY TYPE:	740
ADDRESS:	6667 WANDERMERE CT		TELEPHONE:	(619) 741-5232
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92120
CAPACITY: 6		CENSUS: 4	DATE:	12/18/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Elda Acosta, Facility Manager		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced required Annual Inspection. The facility background information was reviewed prior to the visit. LPA Rodgers identified herself, was granted entry by 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. 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.. Hot water temperature at taps accessible to clients were also compliant. 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]

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Amy Rodgers
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 12/18/2025

NARRATIVE

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(Continued form LIC802)
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. 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.

During today’s visit there were 4 residents on the facility premise. The department observed Resident #1, #2, and #3 beds to have full bed rails with no doctors orders and the Residents #1,#2, and #3 were not on hospice. Facility manager Elda Acosta removed the bed rails during the visit.

Upon entry into the facility the the Department noted a latch device on the inside of the front door that would prevent immediate exit form the facility. Photos were taken and Facility Manager Elda Acosta removed the locking device during the visit.

There were deficiencies observed and cited during today's annual inspection and may be found on the LIC809-D page. LPA requested facility manager Acosta to remove the full bedrails as well as the delayed egress device from the front door during the visit. Acosta explained they may be submitting a prohibited exception waiver for 3 of 4 residents in care to CCLD. Forms are available at www.ccld.ca.gov.

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.

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Amy Rodgers
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/18/2025 04:09 PM - It Cannot Be Edited

Created By: Amy Rodgers On 12/18/2025 at 12:03 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: 12/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(e)(2)

Care of Persons with Dementia

(e) Licensees that use delayed egress devices on exterior doors and perimeter fence gates shall meet the following initial and continuing requirements: (2) The licensee shall ensure that the fire clearance includes approval of delayed egress devices. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 4 of 4 residents (R1, R2, R3,R4) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/19/2025
	Plan of Correction
1 2 3 4	Faciflity manger Elda Acosta removed the lock during the during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

	Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:

	Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 12/18/2025 04:09 PM - It Cannot Be Edited

Created By: Amy Rodgers On 12/18/2025 at 12:03 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: 12/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 3 of 4 residents (R1, R2, R3) which poses an potential, safety or personal rights risk to persons in care.
	POC Due Date: 12/19/2025
	Plan of Correction
1 2 3 4	Faciflity manger Elda Acosta removed the bed rails in all three beds the during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

	Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:

	Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025

LIC809 (FAS) - (06/04)

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