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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603208
Report Date: 11/20/2024
Date Signed: 11/20/2024 05:47:12 PM

Document Has Been Signed on 11/20/2024 05:47 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:ALYCHRIS SENIOR BOARD AND CAREFACILITY NUMBER:
374603208
ADMINISTRATOR/
DIRECTOR:
BANTING, CONSUELOFACILITY TYPE:
740
ADDRESS:8536 MENKAR ROADTELEPHONE:
(858) 935-9037
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 6CENSUS: 6DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Administrator, Connie BantingTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility by Staff, Esperanza Faber Emnas, Administrator, Connie Banting was present.

LPA, accompanied by administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, toilets, and showers were in working order. The window screen in the living room had an opening due to an air conditioning unit not fitted to the window, allowing exposure to outside. 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. Hot water temperature at taps accessible to residents measured at 138 F.. The administrator placed a warning sign over the faucets to warn residents/staff of the hot water temperature. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas.

No pools or bodies of water were observed on the premises. Per the administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files did not contain required documents for staff and/or residents. Confidential records were stored in locked areas. The facility's liability insurance has expired.

Deficiencies were observed and cited during today's annual inspection. Advisory Notes were also issued. An exit interview was conducted with Administrator to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
Document Has Been Signed on 11/20/2024 05:47 PM - It Cannot Be Edited


Created By: Natasha Persaud On 11/20/2024 at 02:47 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: ALYCHRIS SENIOR BOARD AND CARE

FACILITY NUMBER: 374603208

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure the hot water temperature was within regulation for 6 out of 6 {R1-R6] residents, which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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The administrator posted a warning sign to include the hot water temperature above faucets used by residents. Administrator also contacted a plumber, who will be arriving at the facility today to make adjustments. Administrator agreed to submit a video of a water thermometer under the running hot water used for residents and submit by POC due 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:Robyn Clark
LICENSING EVALUATOR NAME:Natasha Persaud
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2024 05:47 PM - It Cannot Be Edited


Created By: Natasha Persaud On 11/20/2024 at 02:47 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: ALYCHRIS SENIOR BOARD AND CARE

FACILITY NUMBER: 374603208

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not ensure staff have CPR training for 3 out of 4 [S1-S3] staff which poses a potential health and risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Administrator stated staff will attend CPR training, once completed, administrator will submit proof of training by POC due.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review, the licensee did not ensure staff received required training for 3 out of 4 [S1-S3] staff, which poses a potential health and safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Administrator stated staff will attend required training, once completed, administrator will submit proof of training by POC due.
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:Robyn Clark
LICENSING EVALUATOR NAME:Natasha Persaud
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 11/20/2024 05:47 PM - It Cannot Be Edited


Created By: Natasha Persaud On 11/20/2024 at 02:47 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: ALYCHRIS SENIOR BOARD AND CARE

FACILITY NUMBER: 374603208

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review, the licensee did not conduct/document disaster drills for 3 out of 4 [S1-S3] staff, which poses a potential health and safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Administrator stated she will conduct a disaster drill and document requirements by POC due date.
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 observations and interviews, the licensee did not obtain written orders for bed rails for 6 out of 6 [R1-R6] residents which poses a potential health and safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Administrator agreed to obtain written orders from a physician indicating the need for the postural support/bed rail by POC due date.
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:Robyn Clark
LICENSING EVALUATOR NAME:Natasha Persaud
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2024 05:47 PM - It Cannot Be Edited


Created By: Natasha Persaud On 11/20/2024 at 03:36 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: ALYCHRIS SENIOR BOARD AND CARE

FACILITY NUMBER: 374603208

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review, the licensee did not obtain an annual medical assessment for 1 out of 6 [R3] residents, which poses a potential health and safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Administrator stated she will obtain a current medical assessment for R3 by POC due date.
Type B
Section Cited
CCR
87506(a)
Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not ensure resident records contained required documentation for 6 out of 6 [R1-R6] residents, which poses a potential health and safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Administrator stated all resident records will be updated by POC due date.
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:Robyn Clark
LICENSING EVALUATOR NAME:Natasha Persaud
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
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