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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603836
Report Date: 10/17/2024
Date Signed: 10/17/2024 02:46:37 PM

Document Has Been Signed on 10/17/2024 02:46 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 CAREFACILITY NUMBER:
374603836
ADMINISTRATOR/
DIRECTOR:		ALOZIE, EDWARDFACILITY TYPE:
740
ADDRESS:966 BOLLENBACHER STREETTELEPHONE:
(619) 957-6133
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 6CENSUS: 6DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Edward Alozie, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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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 resident Elaine Meaole. LPA discussed the purpose of the visit with Assistant Manager Bridget Alozie and Licensee Edward Alozie who 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 in at any given time at the facility site. Facility is approved for two (2) hospice residents. 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 Licensee 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. The facility had ample Personal Protective Equipment as a part of their infection control protocols. 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 72 degrees Fahrenheit (F). Hot water temperature at taps accessible to residents were also compliant: kitchen sink measured hot water at 115.3 degrees F; sink in staff restroom #1 delivered hot water at 120 degrees F; sink in restroom #2 delivered hot water at 114.6 degrees F; sink in restroom #3 delivered hot water at 116.8 degrees F; and back room sink delivered hot water at 107 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 or poisons accessible to residents. Medications were properly labeled, as required, and stored in a locked cabinet. LPA inspected the medication area and found that medications were properly labeled and stored. The facility-maintained medication logs which LPA reviewed.

[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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: SENIORS DIGNITY HOME AND CARE
FACILITY NUMBER: 374603836
VISIT DATE: 10/17/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

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 (03) and serviced within the last 12 months. First aid kit was complete and readily accessible.

LPA interviewed residents, and reviewed staff and resident records. During today’s visit there were 6 residents on the facility premise. 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.

There were deficiencies observed and cited during today's annual inspection and may be found on the LIC809-D page of this report.

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, Residential Infection Control Plan [LIC 9282 (6/23)], and current copy Certificate of Liability Insurance to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/17/2024 02:46 PM - It Cannot Be Edited


Created By: Carmen Lopez On 10/17/2024 at 01:59 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: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 6 residents [R1, R2, R3, and R4] did not have an updated Physician's Report (LIC602) on file which posed a potential health risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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The Licensee agreed to obtain a copy of the residents Physician's Report (LIC602) by POC due date of 11/15/2024.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 [R2] resident's did not have a copy of their TB diagnosis in their file which posed a potential health risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee agreed to obtain a copy of the TB diagnosis on the resident's LIC602 and place on file by POC due date, 11/15/2024.
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:Jennifer Lott
LICENSING EVALUATOR NAME:Carmen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/17/2024 02:46 PM - It Cannot Be Edited


Created By: Carmen Lopez On 10/17/2024 at 01:59 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: 10/17/2024

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 LPA observation of record review, the licensee did not comply with the section cited above in none of the quarterly fire drills for 2024 were completed which posed a potential safety risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Facility agreed to conduct a drill for the current month by POC due date, 10/31/2024. Licensee also agreed to submit a drill in December 2024 as their last quarterly drill for the year and continue quarterly drills the following year.
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:Jennifer Lott
LICENSING EVALUATOR NAME:Carmen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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