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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604697
Report Date: 08/08/2024
Date Signed: 08/08/2024 03:36:28 PM

Document Has Been Signed on 08/08/2024 03:36 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:FAITH VILLAFACILITY NUMBER:
374604697
ADMINISTRATOR/
DIRECTOR:		DEGUZMAN,MA. MEVYLFACILITY TYPE:
740
ADDRESS:42 SIERRA WAYTELEPHONE:
(732) 829-1627
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 5DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Caregiver Marga Ciruela, Administrator Ma Mevyl Deguzman, and Manager Aries DeguzmanTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Marga Ciruela. LPA also met with Administrator Ma Mevyl Deguzman and Manager Aries Deguzman, who arrived later during the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) residents, of which all may be ambulatory or non-ambulatory but none may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of five (5) residents in care, of which all were non-ambulatory and none were bedridden. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and none of these were present.

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. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. 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’s ambient internal temperature was complaint at 76 F. Hot water temperature at taps accessible to residents were all compliant: Kitchen Sink was 117.3 F, Bathroom #1 Sink was 115.2 F, and Bathroom #2 Sink was 113.7 F. Appliances to preserve perishable food were also all compliant in temperature: Kitchen Refrigerator was 39 F and Kitchen Freezer was 0 F. Garage Refrigerator was 37 F and Garage Freezers were 0 F and 0 F, respectively. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present.

[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 08/08/2024 03:36 PM - It Cannot Be Edited


Created By: Dang Nguyen On 08/08/2024 at 02:22 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: FAITH VILLA
FACILITY NUMBER: 374604697

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(b)(2)(C)
Infection Control Requirements
(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around residents and annually thereafter.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not ensure that 5 of 5 staff (S1 through S5) were trained in the proper use of all required PPE annually. This posed a potential health risk to persons in care.
POC Due Date: 09/08/2024
Plan of Correction
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Licensee agreed to have its Registered Nurse lead a training for its current staff to cover both the facility's Infection Control Plan and the proper donning and doffing of PPE (to include surgical masks, N-95 respirators, face shields, gowns, and gloves). Licensee agreed to E-mail a copy of the training sign-in sheet to LPA, by the POC due date.
Type B
Section Cited
HSC
1569.695(b)
Other Provisions
(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not ensure that 5 of 5 staff (S1 through S5) were trained annually on the facility's emergency/disaster plan and their roles and responsibilities under it. This posed a potential safety risk to persons in care.
POC Due Date: 09/08/2024
Plan of Correction
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Licensee agreed to lead a training for its current staff to cover the facility's LIC610E Emergency/Disaster Plan and the staff's individual roles and responsibilities under it. Licensee agreed to E-mail a copy of the training sign-in sheet to LPA, by the POC due 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:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/08/2024 03:36 PM - It Cannot Be Edited


Created By: Dang Nguyen On 08/08/2024 at 02:22 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: FAITH VILLA
FACILITY NUMBER: 374604697

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

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
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Based on records review and manager interview: Licensee did not conduct an emergency/disaster drill at least quarterly for each shift. This posed a potential safety risk to 5 of 5 residents (R1 through R5) in care.
POC Due Date: 09/08/2024
Plan of Correction
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Licensee agreed to perform three (3) emergency/disaster drills. One will be on the AM shift (6:00 AM to 2:00 PM), one will be on the PM shift (2:00 PM to 10:00 PM) and one will be on the overnight NOC shift (10:00 PM to 6:00 AM). Licensee agreed to E-mail written proof of drill completions to LPA, 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: FAITH VILLA
FACILITY NUMBER: 374604697
VISIT DATE: 08/08/2024
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[CONTINUED FROM LIC 809]

There were no sharp objects, toxic chemicals/poisons, active fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. 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 detector, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguisher was serviced within the last twelve (12) months. A complete first aid kit was present and readily accessible. Required licensing postings were observed in visible areas of the facility. Licensee also presented proof of current/active business liability insurance.

LPA reviewed all residents’ records and multiple staff records. LPA also interviewed multiple residents and multiple staff. During records review, LPA observed, and manager interview confirmed: While Licensee performed some emergency/disaster drills at the facility over the last year, they were less than the required frequency of one drill per shift, per quarter. Licensee also had not trained its staff on the facility’s Emergency/Disaster Plan (i.e., LIC610E) initially or within the last twelve (12) months. (Regulation requires staff to be trained on this topic as least once per year). Licensee had also not retrained its staff on the correct use of Personal Protective Equipment (PPE) within the last twelve (12) months. The last time staff received PPE training was 01-11-2023. (Regulation require staff to be trained on this topic at least once per year).

Two (2) deficiencies were cited per California Health and Safety Code, and one (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued Technical Assistance (TA) regarding staff auditory alert devices on exit doors (refer to the attached LIC 9102-TA page).

An exit interview was conducted with Ma Mevyl Deguzman and Aries Deguzman, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TA page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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