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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603895
Report Date: 09/02/2025
Date Signed: 09/02/2025 05:30:57 PM

Document Has Been Signed on 09/02/2025 05:30 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:CHULA VISTA HOME CAREFACILITY NUMBER:
374603895
ADMINISTRATOR/
DIRECTOR:		EVA PARASFACILITY TYPE:
740
ADDRESS:1287 TOBIAS DRIVETELEPHONE:
(619) 869-8247
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 3DATE:
09/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Caregiver Nancydita "Nancy" Gala and Administrator Eva ParasTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Nancydita “Nancy” Gala. LPA then met with Administrator Eva Paras, who arrived shortly after.

According to the facility’s license, the facility has a maximum capacity for six (6) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of three (3) residents in care, and all were non-ambulatory status. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter doors, and neither of these were present.

LPA, accompanied by Licensee’s staff, toured the interior and exterior of the facility and inspected all common areas and resident bedrooms. LPA interviewed all residents in care, and multiple staff. LPA reviewed care records for all residents, and personnel records for all active staff.

During the facility tour, LPA observed, and manager interview confirmed: The facility’s dedicated telephone line was non-working. [During today's visit, Licensee contacted their phone service provider to make an 09/04/2025 appointment to remedy this.] The facility’s fire extinguisher had not been professionally serviced/inspected since 2022. (This was required to be done annually.) Where tested, hot water temperature at taps used by residents were initially too cold: Bathroom #1 Sink was 98.6 F, Bathroom #2 Sink was 98.6 F, and Bathroom #3 Sink was 98.2 F. [CONTINUED ON LIC 809-C, 1 of 2]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: CHULA VISTA HOME CARE
FACILITY NUMBER: 374603895
VISIT DATE: 09/02/2025
NARRATIVE
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[CONTINUED FROM LIC 809] (Regulation required hot water temperature at these taps to be between 105 F and 120 F). [During today’s inspection, adjustments were made to the facility’s water heater settings, which brought these taps back into the complaint temperature range.]

Beyond the above, the facility’s physical plant was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 75 F. Appliances to preserve perishable food were also compliant in temperature. There was at least two (2) days of perishable food, and at least seven (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 residents. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Carbon monoxide detector, smoke detectors, night lights, and emergency lighting were working. No fireplaces or pools/bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Licensee presented proof of current business liability insurance.

During a review of resident records, LPA observed, and manager interview confirmed: For 3 of 3 residents [Resident #1 (R1), Resident #2 (R2), and Resident #3 (R3)], Licensee did not within the last twelve (12) months arrange a care conference meeting to review the respective resident’s plan of care, as required. (Regulation requires such meetings to include the resident themselves, their responsible person, their home health or hospice agency personnel where applicable, and facility staff.) [See LIC811 Confidential Names List for a description of select person identifiers used in this report.]


[CONTINUED ON LIC 809-C, 2 of 2]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
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: CHULA VISTA HOME CARE
FACILITY NUMBER: 374603895
VISIT DATE: 09/02/2025
NARRATIVE
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[CONTINUED FROM LIC 812-C, 1 of 2]

During a review of training and administrative records, LPA observed, and manger interview confirmed: Licensee did not ensure that 6 of 6 staff [Staff #1 (S1) through Staff #6 (S6)] had been trained on Personal Protective Equipment (PPE) within the last year, as required. Licensee did not maintain a written LIC610E Emergency Disaster Plan (or equivalent document) which satisfies the requirements of HSC 1569.695. Licensee also did not perform quarterly disaster drills, as required.

Four (4) deficiencies was cited per California Code of Regulations, Title 22, and two (2) deficiencies were cited per California Health and Safety Code (refer to the LIC809-D pages). Plans of Correction were jointly developed with the Licensee. LPA issued one (1) Technical Violation (TV) regarding a videoconferencing device dedicated for resident use (refer to the LIC9102-TV page). LPA also issued Technical Assistance (TA) regarding refresher training for staff on California Mandated Reporting requirements (refer to the LIC9102-TA page).

An exit interview was conducted with Administrator Eva Paras, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV page, the LIC9102-TA page, the LIC811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2025
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 09/02/2025 05:30 PM - It Cannot Be Edited


Created By: Dang Nguyen On 09/02/2025 at 03:41 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: CHULA VISTA HOME CARE
FACILITY NUMBER: 374603895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87311
Telephones
All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and manager interview, Licensee did not ensure that the facility's telephone service was working. This posed an immediate health, safety, and personal rights risk to 3 of 3 residents (R1, R2, and R3) in care.
POC Due Date: 09/03/2025
Plan of Correction
1
2
3
4
During today's visit, Licensee contacted their telephone service provider and made an appointment for 09/04/2025 for the facility's phone line to be reactivated. This action resolved the immediate risk. LPA recored the cell phone numbers of multiple live-in staff, in the interim.
Type A
Section Cited
CCR
87203
87203 Fire Safety: “All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.” This requirement was not met, as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and manager interview, Licensee did not maintain the facility in continuous conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire. This posed an immediate safety risk to 3 of 3 residents [R1, R2, and R3] in care.
POC Due Date: 09/03/2025
Plan of Correction
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2
3
4
Licensee agreed to either have the facility’s fire extinguisher professionally-serviced or to purchase a new extinguisher, and to send a photo of either the updated service tag or the purchase receipt to LPA, by the 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 09/02/2025 05:30 PM - It Cannot Be Edited


Created By: Dang Nguyen On 09/02/2025 at 03:41 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: CHULA VISTA HOME CARE
FACILITY NUMBER: 374603895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(b)(2)(C)
(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around residents and annually thereafter.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not ensure that 6 of 6 staff (S1 through S6) received training on the proper use of all required PPE within the last year. This posed a potential health risk to 3 of 3 residents (R1, R2, and R3) in care.
POC Due Date: 10/02/2025
Plan of Correction
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Licensee agreed to train all current staff on PPE. The training will include hands-on practice and will cover: a) handwashing, b) how and how often to disinfect commonly touched surfaces, c) how to correctly don and doff surgical masks, N-95 respirators, face shields, gowns, and gloves, d) how perform an N-95 seal check, and e) how to correctly set up a COVID-19 isolation bedroom. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date. Going forward, Licensee agreed to repeat this training at least annually.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 09/02/2025 05:30 PM - It Cannot Be Edited


Created By: Dang Nguyen On 09/02/2025 at 03:41 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: CHULA VISTA HOME CARE
FACILITY NUMBER: 374603895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
1
2
3
4
Based on LPA measurement via thermometer, Licensee did not maintain hot water temperature controls to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degrees F and not more than 120 degrees F. This posed a potential health and personal rights risk to 3 of 3 residents (R1, R2, and R3) in care.
POC Due Date: 09/02/2025
Plan of Correction
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2
3
4
During today’s inspection, adjustments were made to the facility’s water heater settings, which brought said water taps back into the complaint temperature range. The Plan of Correction is Satisfied.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
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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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 09/02/2025 05:30 PM - It Cannot Be Edited


Created By: Dang Nguyen On 09/02/2025 at 03:41 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: CHULA VISTA HOME CARE
FACILITY NUMBER: 374603895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and manager interview, for 3 of 3 residents (R1, R2, and R3), Licensee did not within the last 12 months arrange a meeting with the resident and required individuals to review and revise the written record of care. This posed a potential health risk to persons in care.
POC Due Date: 10/02/2025
Plan of Correction
1
2
3
4
For R1, R2, and R3 each, Licensee agreed to conduct a care conference with their responsible person (and home health/hospice personnel, as applicable) to review the resident's facility Plan of Care, updating it as needed. All parties to the meeting will sign. Licensee agreed to E-mail proof of care conference completion to LPA, by the POC due date. Going forward, Licensee agreed to faciliate such care conferences at least once every 12 months for each resident.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2025 05:30 PM - It Cannot Be Edited


Created By: Dang Nguyen On 09/02/2025 at 03:41 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: CHULA VISTA HOME CARE
FACILITY NUMBER: 374603895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and manager interview, Licensee did not have a written emergency and disaster plan that included all of the required elements. This posed a potential safety risk to 3 of 3 residents (R1, R2, and R3) in care.
POC Due Date: 10/02/2025
Plan of Correction
1
2
3
4
During today's visit, LPA provided Licensee with a copy of form LIC610E. Licensee agreed to develop a written LIC610E Emergency Disaster Plan which meets all the elements required by HSC 1569.695, and to E-mail it to LPA, by the POC due date.
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
1
2
3
4
Based on records review and manager interview, Licensee did not conduct a disaster drill at least quarterly for each shift, and did not vary the type of emergency covered from quarter to quarter, taking into account different emergency scenarios. This posed a potential safety risk to 3 of 3 residents (R1, R2, and R3) in care.
POC Due Date: 10/02/2025
Plan of Correction
1
2
3
4
Licensee agreed to conduct three (3) disaster drills (one on AM shift, one on PM shift, and one on NOC shift), and to E-mail proof of drill completion to LPA, by the POC due date. Going forward, Licensee agreed to drill each shift at least once per quarter, and to vary the type of disaster covered from one quarter to the next, and to keep written records of all drills.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2025


LIC809 (FAS) - (06/04)
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