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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604439
Report Date: 05/07/2024
Date Signed: 05/07/2024 03:50:35 PM

Document Has Been Signed on 05/07/2024 03:50 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KELLY'S CEDAR VILLAFACILITY NUMBER:
374604439
ADMINISTRATOR/
DIRECTOR:		WELKER, GARRETTFACILITY TYPE:
740
ADDRESS:1341 BOYLE AVENUETELEPHONE:
(619) 504-5049
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 5DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Garrett Walker, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility for a required annual inspection. The LPA was allowed entrance into the facility and met with Administrator, Garrett Welker. The LPA informed the Administrator of the purpose for the visit. The facility currently has an approved Hospice Waiver for six (6) residents. The inspection included the following:

Physical Plant: The facility consists of six (6) resident bedrooms, one (1) staff room, a dinning area, an office, a living space, an open kitchen, a laundry room, and a patio with sufficient seating and space for activities. The LPA inspected the ground level of the home (staff rooms and independent living) and observed no concerns. There are no bodies of water located on the property. According to Administrator Welker, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats or strips present. The carbon monoxide and smoke detectors were tested by the Administrator and were observed to be in operating condition. The home was kept clean and free of any odors.

Food Service: There is a minimum of 2 days supply of perishable foods and 1 week's supply of non-perishable foods available. Sufficient supplies were available for resident's dinning use.

Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Training on Dementia Care, Postural Supports, Restricted Health Conditions, and Hospice Care was observed to be on file. The LPA was informed there is currently one (1) resident in care who is receiving hospice services. A hospice care plan was on file at the facility. There is a disaster and mass casualty plan in place. Emergency Drills are being completed. All services requiring specialized skill are being performed by a staff member of the facility, who is qualified as an appropriately
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KELLY'S CEDAR VILLA
FACILITY NUMBER: 374604439
VISIT DATE: 05/07/2024
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skilled professional. The Physician's Report for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) for Resident Four (R4) deemed the resident as bedridden. The facility does not currently have a fire clearance on file for a bedridden resident. A citation and civil penalty will be issued.

Medication Review: The LPA reviewed medications for two residents. The medications were observed to be well organized and inaccessible to unauthorized individuals.

An exit interview was conducted with Administrator Welker in which this report was reviewed and a copy was provided, in addition to the LIC 811, LIC 421IM, and instructions on appeal rights.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/07/2024 03:50 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 05/07/2024 at 03:27 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KELLY'S CEDAR VILLA
FACILITY NUMBER: 374604439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations - Capacity and Ambulatory Status: A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in one out of five residents who is deemed Bedridden. The Physician's Report for Residential Care Facilities for the Elderly (RCFE) (LIC 602A) for Resident Four (R4) deemed the resident as bedridden. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
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Administrator stated R4 will be transported to another, sister, facility which currently has a bedridden fire clearance. Administrator reported written notification will be submitted by the POC due date.
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
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