374604611-4-1-2025-08-AS-HROS-DF7USQ-20250328155043

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604611
Report Date: 03/28/2025
Date Signed: 04/01/2025 10:26:57 AM

Document Has Been Signed on 04/01/2025 10:26 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	IDEAL HOME CARE		FACILITY NUMBER:	374604611
ADMINISTRATOR/ DIRECTOR:	HULSEY, JOSEFINA I.		FACILITY TYPE:	740
ADDRESS:	3337 STOCKMAN STREET		TELEPHONE:	(619) 292-2668
CITY:	NATIONAL CITY	STATE: CA	ZIP CODE:	91950
CAPACITY: 6		CENSUS: 3	DATE:	03/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:50 PM
MET WITH:	Administrator Josefina Hulsey		TIME VISIT/ INSPECTION COMPLETED:	03:55 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) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted by, identified themselves to and discussed the purpose of the visit with Administrator Josefina Hulsey. The facility's license shows a maximum capacity of six (6) residents, of which four (4) may be non-ambulatory and two (2) may be bedridden. During today’s inspection, there were a total of three (3) residents in care. LPA with Administrator Hulsey toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, 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 resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food. LPA observed expired canned goods in the pantry. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Administrator Administrator Hulsey, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC809-C]

NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Hannah Rodgers
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: IDEAL HOME CARE	FACILITY NUMBER: 374604611
	VISIT DATE: 03/28/2025

NARRATIVE

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LPA reviewed facility records. Administrator Hulsey could not provide proof of conducted quarterly emergency drills, as required. Confidential records were stored in locked areas. For one (1) of the three (3) resident records reviewed the Licensee did not possess a written Needs and Services Plan or equivalent care plan for the client which had been updated within the last year, as required.

Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages) and one (1) deficiency was cited per California Health and Safety Code. Plans of Correction were jointly developed with Administrator Hulsey.

An exit interview was conducted with Administrator Hulsey, to whom a copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided for today’s visit.

NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Hannah Rodgers
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 04/01/2025 10:26 AM - It Cannot Be Edited

Created By: Hannah Rodgers On 03/28/2025 at 03:04 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: IDEAL HOME CARE	FACILITY NUMBER: 374604611
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above as there were expired canned goods in the pantry which posed a potential health and safety risk to three (3) out of three (3) persons in care.
	POC Due Date: 04/18/2025
	Plan of Correction
1 2 3 4	Licensee agrees to immediately discard all expired food items and regularly check food for expiration dates and discard or use by the expiration date. Licensee agreed to contact and notify LPA as soon as all of the expired canned goods are removed, but no later than the POC due date.

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one (1) of three (3) resident files reviewed during this inspection, Licensee did not ensure that Resident #1's Needs and Services Plan was updated at least annually. This posed a potential health, safety, and personal rights risk to persons in care.
	POC Due Date: 04/18/2025
	Plan of Correction
1 2 3 4	Licensee agreed to complete a current LIC625 Appraisal/Needs and Services Plan for Resident #1, and to have the plan reviewed and signed by the resident's responsible person. Licensee agreed to E-mail the signed/completed LIC625 to the Department, by the POC due date. Licensee agreed to complete/update LIC625's for all other current and future residents, and to update them at least once per year.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:

	Hannah Rodgers
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 04/01/2025 10:26 AM - It Cannot Be Edited

Created By: Hannah Rodgers On 03/28/2025 at 03:04 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: IDEAL HOME CARE	FACILITY NUMBER: 374604611
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2025

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as the licensee could not provide documentation of the drills which posed a potential health and safety risk to three (3) out of three (3) persons in care.
	POC Due Date: 04/18/2025
	Plan of Correction
1 2 3 4	Licensee agrees to conduct training for all current staff on its existing LIC610D Emergency/Disaster Plan and the staff's roles/responsibilities under it. Licensee agreed to submit the training sign-in sheet to LPA, by the POC due date. Going forward, Licensee agreed to conduct quarterly emergency drills and document said drills.

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.

	Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:

	Hannah Rodgers
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

LIC809 (FAS) - (06/04)

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