374603746-8-28-2024-08-AS-THOS-D8KVP4-20240828163606

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603746
Report Date: 08/28/2024
Date Signed: 08/28/2024 04:37:09 PM

Document Has Been Signed on 08/28/2024 04:37 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:	CHHINA'S SENIOR GUEST HOUSE		FACILITY NUMBER:	374603746
ADMINISTRATOR/ DIRECTOR:	CHHINA, JIWAN S		FACILITY TYPE:	740
ADDRESS:	8632 SPRING VISTA WAY		TELEPHONE:	(619) 337-5201
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY: 6		CENSUS: 5	DATE:	08/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:51 AM
MET WITH:	Jiwan Chhina, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:36 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Jiwan Chhina, Administrator, to whom LPA discussed the purpose of the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) residents. During today’s inspection, five (5) residents were at home.

LPA, accompanied by Chhina, 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, 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 client activities. The facility’s ambient internal temperature was compliant at 72 F. Hot water temperature at taps accessible to residents were all compliant: Bathroom sinks were 105.1 F.

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, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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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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: CHHINA'S SENIOR GUEST HOUSE	FACILITY NUMBER: 374603746
	VISIT DATE: 08/28/2024

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per the Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed Chhina. Interview did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Client files were missing required documents. Confidential records were stored in locked areas. House Manager presented proof of current/active business liability insurance and surety bond. Staff had their first aid cards in their files.

Deficiencies were observed and cited during today's visit.

An exit interview was conducted with Chhina, to whom copies of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/28/2024 04:37 PM - It Cannot Be Edited

Created By: Tiffany Holmes On 08/28/2024 at 03:14 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: CHHINA'S SENIOR GUEST HOUSE	FACILITY NUMBER: 374603746
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87456(a)(2)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and a record review, the licensee did not comply with the section cited above in 5 out of 5 persons (R1-R5) which poses a potential safety and personal rights risk to persons in care.
	POC Due Date: 09/04/2024
	Plan of Correction
1 2 3 4	Licensee will complete all pre appraisals for the 5 residents and have them signed and dated.POC due to CCL by 09/04/2024

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation & record review the licensee did not comply with the section cited above in 1 out of 5 residents (R1) which poses a personal rights risk to persons in care.
	POC Due Date: 09/04/2024
	Plan of Correction
1 2 3 4	Licensee will complete the admission agreement for R1 and have it completed and signed by POC date of 09/04/2024

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:

Denise Powell

LICENSING EVALUATOR NAME:

Tiffany Holmes

LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC809 (FAS) - (06/04)

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