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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604474
Report Date: 10/09/2024
Date Signed: 10/09/2024 05:01:34 PM

Document Has Been Signed on 10/09/2024 05:01 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:VISTA SERENO RCFEFACILITY NUMBER:
374604474
ADMINISTRATOR/
DIRECTOR:		MASE, DOMINIQUEFACILITY TYPE:
740
ADDRESS:2725 VISTA SERENO CT.TELEPHONE:
(619) 405-3586
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY: 4CENSUS: DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:01 PM
MET WITH:Licensee/Administrator Dominique MaseTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, care giver Felimon Raturat to whom she discussed the purpose of the visit. Later Licensee/Administrator Dominique Mase joined the visit.

According to the facility’s license, the facility has a maximum capacity of four (4) residents all of which may be non-ambulatory. During today’s inspection, there were a total of four (4) clients in care, all of which were non-ambulatory. This facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant. There were two Refrigerator/Freezer units both of which had appropriate temperatures. There were two bathrooms accessible to clients both of which the hot water tap temperature was 116 degrees Fahrenheit

(Continued on 809-C)

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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Document Has Been Signed on 10/09/2024 05:01 PM - It Cannot Be Edited


Created By: Amy Rodgers On 10/09/2024 at 03:23 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: VISTA SERENO RCFE
FACILITY NUMBER: 374604474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (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 is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in 4 of 4 residents (R1- R4) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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On 10/9/2024 Licensee replaced broken and non exitent locks on medication cabintet, while LPA Rodgers was at the facility. Licensee stated he will conduct In-Service training regarding locking medications and submit proof of training by 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:Denise Powell
LICENSING EVALUATOR NAME:Amy Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024


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: VISTA SERENO RCFE
FACILITY NUMBER: 374604474
VISIT DATE: 10/09/2024
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(Continued from 809)
There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required. Confidential records were stored in locked areas.

Upon LPA's arrival, she observed that keys were hanging from the medication storage cabinet locks and part of the cabinet did not have locks and one lock was damaged. There were medications in the cabinet, so a deficiency was issued.

No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kit were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed multiple staff and one client and reviewed multiple staff and client records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Licensee also presented proof of current/active business liability insurance and surety bond

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 the licensee. An exit interview was conducted with Licensee/Administrator Dominique Mase, 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: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC809 (FAS) - (06/04)
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