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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604668
Report Date: 10/30/2024
Date Signed: 10/30/2024 06:13:50 PM

Document Has Been Signed on 10/30/2024 06:13 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 EASTFACILITY NUMBER:
374604668
ADMINISTRATOR/
DIRECTOR:		ENGDAW, AMSALFACILITY TYPE:
740
ADDRESS:2337 CAMINO DEL RIO SOUTHTELEPHONE:
(619) 501-1788
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY: 6CENSUS: 6DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Caregiver Alfredo PaclebTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Juliana Barfield, David Roman, 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, identified themselves to, and discussed the purpose of the visit with, Caregiver Alfredo Pacleb.

According to the facility’s license, the facility has a maximum capacity of six (6) residents, all of whom may be non-ambulatory. During today’s inspection, there were a total of six (6) residents in care, and per medical records, all were non-ambulatory. This facility does not feature a secured perimeter or delayed egress doors.

LPAs accompanied by Alfredo Pacleb, toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

Hot water temperature in resident bathroom was compliant. There were at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters observed.

No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
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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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: MISSION VILLA EAST
FACILITY NUMBER: 374604668
VISIT DATE: 10/30/2024
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Deficiencies were 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 Amsal Engdaw, 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2024 06:13 PM - It Cannot Be Edited


Created By: Juliana Barfield On 10/30/2024 at 05:13 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 EAST
FACILITY NUMBER: 374604668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
(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 two out of two staff (S1) and (S2) which posed a potential health and safety risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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Licensee stated that training would be completed for (S1) and (S2) and proof of completion to be provided to CCL by POC date.
Type B
Section Cited
HSC
1569.618(c)(3)
Other provisions
(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 [2) out of (2) staff S1 and S2, which posed a potential health and safety risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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LIcensee agreed to provide certificates of cardiopulonary resuscitation (CPR) 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:Juliana Barfield
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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