374603836-11-13-2023-08-AS-CLOZ-CXK5GL-20231113185656

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603836
Report Date: 11/13/2023
Date Signed: 11/13/2023 06:58:01 PM

Document Has Been Signed on 11/13/2023 06:58 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:	SENIORS DIGNITY HOME AND CARE		FACILITY NUMBER:	374603836
ADMINISTRATOR:	ALOZIE, EDWARD		FACILITY TYPE:	740
ADDRESS:	966 BOLLENBACHER STREET		TELEPHONE:	(619) 957-6133
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92114
CAPACITY: 6		CENSUS: 6	DATE:	11/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Edward Alozie, Licensee		TIME COMPLETED:	07:00 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) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by caregiver Chioma Alozie. LPA discussed the purpose of the visit with caregiver Alozie. Licensee Edward Alozie 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 of which 1 may be bedridden and the facility has a waiver for two (2) hospice residents at the facility at any given time. During today’s inspection, the facility’s current census is 6 residents living at the facility. There were 6 residents present at the facility site during the inspection. LPA, accompanied by caregiver Bridget Alozie, 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. 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 75 degrees Fahrenheit (F). Hot water temperature at taps accessible to residents were also compliant: Kitchen sink was 123.4 degrees F; sink in restroom #1 delivered hot water at 120.4 degrees F; sink in restroom #2 delivered hot water at 120.7 degrees F; and sink in restroom #3 delivered hot water at 125 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 all safely stored. There were no toxic chemicals/poisons accessible to residents. Medications were properly labeled, as required, and stored in locked areas. LPA inspected the medication room and found that medications were properly labeled and stored in a locked cabinet. The facility maintained medication logs which LPA reviewed. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

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: SENIORS DIGNITY HOME AND CARE	FACILITY NUMBER: 374603836
	VISIT DATE: 11/13/2023

NARRATIVE

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No pools or bodies of water on the premises. Per licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were present (02) and serviced within the last 12 months. First aid kits were complete and readily accessible.

LPA reviewed staff and resident records. LPA records review and facility inspection did not raise any licensing concerns. The files which LPA reviewed contained relevant documents. Confidential records were stored in a locked drawer. Required licensing postings were observed in a visible area of the facility.

There was a deficiency observed and cited during today's annual inspection and can be found on the deficiency page along with technical advisories. A plan of correction was jointly developed with the Licensee.

An exit interview was conducted with Licensee Edward Alozie 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 Licensee Alozie 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: Denise Powell
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/13/2023 06:58 PM - It Cannot Be Edited

Created By: Carmen Lopez On 11/13/2023 at 06:11 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: SENIORS DIGNITY HOME AND CARE	FACILITY NUMBER: 374603836
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(d)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 6 residents did not match the medications with the date filled which posed a potential health risk to 1 (R1) persons in care.
	POC Due Date: 11/30/2023
	Plan of Correction
1 2 3 4	Licensee will make an internal form for the date the pharmacy filled the prescription, the date the licensee received the medication, and the date the licensee dispensed the medication to the resident. Licensee will send a copy of the form with the information filled-out to LPA by POC due date, 11/30/23.

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.

SUPERVISOR'S NAME:

Denise Powell

LICENSING EVALUATOR NAME:

Carmen Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC809 (FAS) - (06/04)

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