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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604383
Report Date: 02/24/2025
Date Signed: 02/24/2025 05:29:56 PM

Document Has Been Signed on 02/24/2025 05:29 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:AMARIAH HOME CAREFACILITY NUMBER:
374604383
ADMINISTRATOR/
DIRECTOR:		JR. ALVELA, JOSEPH P.FACILITY TYPE:
740
ADDRESS:1046 HELIX AVETELEPHONE:
(619) 731-1535
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 5DATE:
02/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Caregiver Mary Phets and Licensee Joseph P. AlvelaTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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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 Mary Phets. LPA then met with Licensee and Administrator Joseph Alvela, who arrived later during the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) residents, of whom all may be ambulatory or non-ambulatory, and one (1) may be bedridden (in Bedroom #3 only). According to LIC602 Physician’s Reports, staff interviews, and LPA observation: During this annual inspection, there were a total of five (5) residents in care [Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), Resident #5 (R5)], of whom all were non-ambulatory, per their respective doctors. [See LIC811 Confidential Names list pages for a description of select person identifiers used in this report.] The facility’s license did not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present.

During this inspection, LPA interviewed all residents and multiple staff. LPA reviewed the care records for all residents and the personnel and training files for all current staff. LPA also toured the interior and exterior of the facility and inspected all common areas and bedrooms. The facility 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.


[CONTINUED ON LIC 809-C, 1 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
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 7
Document Has Been Signed on 02/24/2025 05:29 PM - It Cannot Be Edited


Created By: Dang Nguyen On 02/24/2025 at 03:52 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: AMARIAH HOME CARE
FACILITY NUMBER: 374604383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not ensure that cleaning solutions and/or poisonous substances, which could pose a danger to residents, were in locked storage and not left unattended. This posed an immediate health and safety risk to 5 of 5 residents (R1 through R5) in care.
POC Due Date: 02/24/2025
Plan of Correction
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During today's visit, LPA handed the bottles of cleaning solutions/chemicals to staff to be relocated to locked cabinets. This resolved the immediate risk. Licensee agreed to retrain all current staff on what items constitute hazards and on their correct storage, and to E-mail the training sign-in sheet to LPA by 03/25/2025.
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care: “(h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not ensure that centrally stored medicines were kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This posed an immediate health and safety risk to 5 of 5 residents (R1 through R5) in care.
POC Due Date: 02/24/2025
Plan of Correction
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During today's visit, LPA handed the unsecured medicines to staff to be relocated to locked cabinets. This resolved the immediate risk. Licensee agreed to retrain all current staff on expectations regarding safe storage of centrally stored medications, and to E-mail the training sign-in sheet to LPA by 03/25/2025.
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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 02/24/2025 05:29 PM - It Cannot Be Edited


Created By: Dang Nguyen On 02/24/2025 at 03:52 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: AMARIAH HOME CARE
FACILITY NUMBER: 374604383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(f)(1)
Incidental Medical and Dental Care Services
(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, for 5 of 5 residents (R1 through R5), Licensee did not have the name, address, and telephone number for both the resident's physician and their dentist readily available. This posed a potential health risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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Licensee agreed to coordinate with residents' responsible persons and to collect the name, address, and telephone number of the primary care physician (PCP) and designated dentist for R1 through R5, and to add this information to those residents' Emergency Contact Sheets (a.k.a, "Facesheets"). Licensee agreed to E-mail the updated facesheets for R1 through R5 to LPA, by the POC due date.
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

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 regularly observe 5 of 5 residents (R1 through R5) for changes in physical functioning, to include unusual weight gains or losses. This posed a potential health risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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Licensee agreed to maintain a record of monthly weight logs for R1 through R5. For residents who would have difficulty standing independently on a scale, Licensee may use alternate methods of monitoring weight (such as arm tape measure). Licensee agreed to take and E-mail current body weight measurements for R1 through R5 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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/24/2025 05:29 PM - It Cannot Be Edited


Created By: Dang Nguyen On 02/24/2025 at 03:52 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: AMARIAH HOME CARE
FACILITY NUMBER: 374604383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025

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 record review and manager interview, Licensee did not have proof that 3 of 3 current staff (S1 through S3) received training on PPE withing the last year, as required. This posed a potential health risk to 5 of 5 residents (R1 through R5) in care.
POC Due Date: 03/25/2025
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, and d) how perform an N-95 seal check. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date.
Type B
Section Cited
CCR
87705(d)
87705 Care of Persons with Dementia: “(d) The licensee shall ensure that the facility has an auditory device or other
staff alert feature to monitor exits on exterior doors…accessible to those residents who may be at risk for
elopement…” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not ensure that the facility had an auditory device (or other staff alert
feature) to monitor exits on 6 of 8 exterior doors which were accessible to residents who may be at risk for
elopement. This posed a potential safety risk to 3 of 5 residents (R1, R2, and R3) in care.
POC Due Date: 03/25/2025
Plan of Correction
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During today’s visit, LPA switched existing staff auditory alert devices, which were affixed to exterior doors (but had
been turned off), back on. This resolved the risk. Licensee agreed to retrain all staff to ensure staff alert devices are
always armed and working on all exterior doors, so long as there is a resident in care who cannot safely leave the
facility unassisted. Licensee agreed to E-mail the training sign in sheet 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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 02/24/2025 05:29 PM - It Cannot Be Edited


Created By: Dang Nguyen On 02/24/2025 at 03:53 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: AMARIAH HOME CARE
FACILITY NUMBER: 374604383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025

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 records review and manager interview, Licensee did not conduct a disaster drill at least quarterly for each shift. This posed a potential safety risk to 5 of 5 residents (R1 through R5) in care.
POC Due Date: 03/25/2025
Plan of Correction
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Licensee agreed to conduct, and document in writing, completion of three (3) disaster drills (one for AM shift, one for PM shift, and one for NOC shift). Licensee agreed 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 emergency covered from quarter to quarter.
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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


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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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: AMARIAH HOME CARE
FACILITY NUMBER: 374604383
VISIT DATE: 02/24/2025
NARRATIVE
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[CONTINUED FROM LIC 809] The facility’s ambient internal temperature was complaint at 79 F. Hot water at taps accessible to residents were also compliant in temperature: Kitchen Sink was 108.5 F, Bathroom #1 Sink was 107.2 F, and Bathroom #2 Sink was 108.1 F. The facility’s refrigerators and freezers, which were used to preserve perishable foods, were also all compliant in temperature. There were at least (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.

No pools or bodies of water observed on the premises. The facility's fireplace was screened. There were no open-faced heaters accessible to residents. Smoke detectors, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Per the Licensee, no firearms or ammunition were kept at the facility. Licensee presented proof of current business liability insurance.

According to their respective LIC602 Physician’s Reports: R1, R2, and R3 were diagnosed with Dementia, while R4 and R5 were diagnosed with Mild Cognitive Impairment (MCI). Even so, R4 was determined by their doctor to be at risk if “allowed direct access to personal grooming and hygiene items.” Per the doctors, none of R1 through R5 could safely store their own prescription medications. Interviews of facility staff showed all residents required staff assistance with storing and taking their medications. Also, per their doctors, none of R1 through R5 would be safe if they left the facility unassisted.

During today’s visit, LPA observed a non-locking drawer in the facility’s kitchen, which contained four (4) bottles of prescription laxative medications and one (1) bottle of cough medicine, all belonging to residents. LPA was able to take out these bottles with staff noticing. [LPA subsequently directed staff to relocate the medicine bottles to a different cabinet that was able to be locked.] Left out in the kitchen was one (1) unattended bottle of dishwashing soap; this needed to be locked when not in active use by staff because of what R4’s doctor wrote about them on their LIC602 (see above). Also, inside the shower of one the facility’s two shared bathrooms was one (1) unattended spray bottle containing a cleaning chemical; this toxin needed to be secured from all residents. LPA was able to take and manipulate these bottles without staff noticing. [LPA subsequently directed staff to relocate these bottles to locked cabinets.]

[CONTINUED ON LIC 809-C, 2 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: AMARIAH HOME CARE
FACILITY NUMBER: 374604383
VISIT DATE: 02/24/2025
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

Licensee had previously installed auditory door chime devices (i.e., “staff alert devices”) on each of its exterior exit doors, as required when caring for persons diagnosed with Dementia. However, during today’s visit, LPA observed that facility staff had manually switched the devices “Off,” rendering them inoperable on six (6) of eight (8) exterior exit doors. [LPA manually switched these devices back to the “On” position and verified they were working.]

During review of client records, LPA observed, and manager interview confirmed: Licensee did not maintain current Primary Care Physician (PCP) name, address, and contact information for R2, R3, and R4. Licensee also did not maintain current designated Dentist name, address, and contact information for R1 through R5. Also, Licensee did not maintain a record of body weights for R1 through R5. (Regulation required Licensee to “regularly observe” clients for changes in physical condition, to include “unusual weight gains or losses.”)

During review of personnel/training records, LPA observed, and manager interview confirmed: Licensee did not have proof that S1 through S3 had received training on Personal Protective Equipment (PPE) within the last year, as was required. Licensee also did not have proof of completion of disaster drills within the last calendar year. (Regulation required Licensee to drill each shift at least once per quarter).

Six (6) deficiencies were cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. 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 Licensee and Administrator Joseph Alvela, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TA page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today's visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC809 (FAS) - (06/04)
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