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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602940
Report Date: 12/29/2022
Date Signed: 12/29/2022 11:51:23 AM

Document Has Been Signed on 12/29/2022 11:51 AM - 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:SERRA MESA GUESTS HOME IIFACILITY NUMBER:
374602940
ADMINISTRATOR:WILFREDO SALAZARFACILITY TYPE:
740
ADDRESS:566 PARKWOOD DRIVETELEPHONE:
(619) 944-3018
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY: 6CENSUS: 2DATE:
12/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:House Manager Evelyn SalazarTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Kayla Hilario conducted an unannounced Case Management Visit. LPA was allowed entry, met with, and described the purpose of the visit to Caregiver Celina Samonte. House Manager Evelyn Salazar and Assistant House Manager Lolita Tisbe arrived during the visit. All staff present have current criminal record clearance.

LPA conducted a wellness check at the facility by touring the facility both inside and outside and observing that residents in care appeared appropriate for the facility.

Today's visit is in response to the self-reported incident which occurred on 11/26/2022 regarding an AWOL of Resident 1 (R1 - see LIC811 Confidential Names List). According to the Special Incident Report (LIC 624), R1
was allowed to leave the facility unassisted to visit a family member on a public bus on Wednesday 11/26/2022 around 08:00 a.m. Facility staff were notified at noon, that the R1 did not show up by noon. Licensee followed appropriate AWOL procedures by notifying authorities in a timely manner and trying to locate the resident.

However, records review and interviews with staff and outside sources, determined that the R1 should not have been allowed to leave on their own. A deficiency was cited during this visit of Title 22 regulation 87411. An 809-D page is attached to this Facility Visit Report.

An exit interview was conducted with the House Manager Evelyn Salazar. A copy of this report and appeal rights (LIC9056 03/22), were provided via hardcopy at the conclusion of the visit.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Kayla Hilario
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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 12/29/2022 11:51 AM - It Cannot Be Edited


Created By: Kayla Hilario On 12/29/2022 at 11:30 AM
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: SERRA MESA GUESTS HOME II
FACILITY NUMBER: 374602940

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2022
Section Cited
CCR
87411(a)

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87411 -Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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Licensee shall read the regulation in its entirety, train staff on this regulation and submit a statement of understanding and training log to CCL by the POC due date of 12/30/2022.
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Based on records review, and interview with staff and outside sources, facility staff were not compentent to provide services neccessary services for 1 of 3 residents by allowing R1 to leave facility unassisted, which causes an immediate health and safety risk to residents 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:John Rante
LICENSING EVALUATOR NAME:Kayla Hilario
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022


LIC809 (FAS) - (06/04)
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