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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604090
Report Date: 06/12/2024
Date Signed: 06/12/2024 02:01:13 PM

Document Has Been Signed on 06/12/2024 02:01 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:ST ANDREWS SUITESFACILITY NUMBER:
374604090
ADMINISTRATOR/
DIRECTOR:
SHERWIN, MARCOSFACILITY TYPE:
740
ADDRESS:17023 ST ANDREWS DRTELEPHONE:
(520) 548-0138
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 6DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Sherwin MarcosTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Administrator Sherwin Marcos.

According to the facility’s license, the facility has a maximum capacity of six (6) residents of whom all may be non-ambulatory, of which one (1) resident may be bedridden. There is an approved hospice waiver for three (3) residents. During today’s inspection, there were a total of six (6) residents and per medical records, all were either ambulatory or non-ambulatory.

LPA, accompanied by Sherwin Marcos toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. 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 clients were all compliant. There were at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no sharp objects, open-faced fireplaces or heaters observed accessible to clients. Medications were labeled, as required, and stored in locked areas.

No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit was complete. Required licensing postings were observed in visible areas of the facility.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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: ST ANDREWS SUITES
FACILITY NUMBER: 374604090
VISIT DATE: 06/12/2024
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Disinfectants/chemicals were observed in an unlocked interior facility room and exterior shed accessible to residents in care. During LPA’s visit, facility staff locked and secured all disinfectants and cleaning solutions, resolving the immediate risk.

A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with Administrator Sherwin Marcos. An exit interview was conducted with Sherwin Marcos to whom a copy of this report, the LIC 809-D and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/12/2024 02:01 PM - It Cannot Be Edited


Created By: Juliana Barfield On 06/12/2024 at 01:24 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: ST ANDREWS SUITES

FACILITY NUMBER: 374604090

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two (2) out of two (2) facility areas which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
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Administrator moved chemicals in unlocked garage cabinet to a locked garage cabinet. Administrator locked outdoor shed where paint and other chemicals were available to residents.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Juliana Barfield
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
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