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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604667
Report Date: 10/30/2024
Date Signed: 10/30/2024 05:18:05 PM

Document Has Been Signed on 10/30/2024 05:18 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:MISSION VILLA WESTFACILITY NUMBER:
374604667
ADMINISTRATOR/
DIRECTOR:
ENGDAW, AMSAL D.FACILITY TYPE:
740
ADDRESS:2335 CAMINO DEL RIO SOUTHTELEPHONE:
(619) 501-1244
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY: 6CENSUS: 5DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:09 PM
MET WITH:Administrator Amsal EngdawTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hannah Rodgers, LPA David Roman, LPA Juliana Barfield and Licensing Program Manager (LPM) Lizzette Tellez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit.  LPAs and LPM were welcomed by and discussed the purpose of the visit to Caregiver Maria Pacleb. Administrator Amsal arrived during the visit. The facility's license shows a maximum capacity of 6 non-ambulatory residents, of which 1 may be bedridden in room #1. During today’s inspection there were 5 residents in care.

LPAs and LPM with Adminstrator Amsal 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, 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 resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. 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 Amsal, 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.


LPAs interviewed staff and residents, and reviewed facility records. During review of resident records LPAs observed that Resident #1-4 (R1-R4), residents with a major neurocognitive disorder, did not have an updated medical assessment and reappraisal. LPAs observed that Staff #1-3 did not have proof of training and a health screening report in their files.

Three deficiencies and one technical violation were cited in accordance with CCR Title 22. An exit interview was conducted with Amsal to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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 10/30/2024 05:18 PM - It Cannot Be Edited


Created By: Hannah Rodgers On 10/30/2024 at 03:54 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: MISSION VILLA WEST

FACILITY NUMBER: 374604667

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 persons (S1-S3) which poses a potential health and safety risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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Licensee agrees to ensure all personel files will have proof of training and send copies to CCL by POC 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2024 05:18 PM - It Cannot Be Edited


Created By: Hannah Rodgers On 10/30/2024 at 04:09 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: MISSION VILLA WEST

FACILITY NUMBER: 374604667

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
All personnel... shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening... performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure...The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents...Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 persons (S1-S3) which poses a potential health and safety risk to persons in care.
POC Due Date: 11/29/2024
Plan of Correction
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Licensee agrees to ensure all personnel files will have a signed health screening report and send copies to CCL by POC date.
Type B
Section Cited
CCR
87705(c)(5)
Each resident with dementia shall have an annual medical assessment as specified in section 87458, Medical Assessment, and a reappraisal done at least annually both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 5 persons (R1-R4) which poses a potential health and safety risk to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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Licensee agrees to ensure all resident files will have an updated Medical Assessment and reappraisal and send copies to CCL by POC 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:Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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