<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604138
Report Date: 08/09/2022
Date Signed: 08/19/2022 09:23:23 AM

Document Has Been Signed on 08/19/2022 09:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PREMIUM CARE SERVICESFACILITY NUMBER:
374604138
ADMINISTRATOR:HAFIZ, SHEIKHFACILITY TYPE:
740
ADDRESS:8243 HYDRA LNTELEPHONE:
(858) 433-7319
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 6CENSUS: 4DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Licensee, Sheikh Hafiz TIME COMPLETED:
02:47 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) Natasha Persaud conducted an unannounced annual required licensing inspection. LPA was greeted and allowed entry into the facility by Staff, Julieta Reyes. LPA met with Licensee, Sheikh Hafiz and Administrator, Nawshaba Siddiky. LPA stated purpose of today’s visit, to verify compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA conducted a tour of the facility and observed the residents in care. In accordance with the Department’s Infection Control, LPA provided consultation, observed, and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, testing, vaccination, screening protocols, and the use of personal protective equipment.

In addition, during the tour of the facility, LPA observed the medication cabinet was not locked, making the medications accessible to residents in care. A deficiency was observed and listed on the attached LIC 809D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Licensee, Sheikh Hafiz whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/19/2022 09:23 AM - It Cannot Be Edited


Created By: Natasha Persaud On 08/09/2022 at 02:14 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: PREMIUM CARE SERVICES
FACILITY NUMBER: 374604138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by not locking medications for 4 out of 4 residents, which poses an immediate health and safety to persons in care.
POC Due Date: 08/10/2022
Plan of Correction
1
2
3
4
Licensee agreed to conduct In-Service training regarding medications. Licensee will submit proof of training by POC due 08/10/22.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Natasha Persaud
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2