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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604697
Report Date: 08/25/2025
Date Signed: 08/25/2025 02:29:22 PM

Document Has Been Signed on 08/25/2025 02:29 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: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: 6DATE:
08/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Caregiver Margarita "Marga" Ciruela and Licensees Mevyl Deguzman and Aries DeguzmanTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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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 Margarita "Marga" Ciruela. LPA then met with Licensees Mevyl Deguzman and Aries Deguzman, who arrived shortly after.

According to the facility’s license, the facility has a maximum capacity for six (6) residents, of whom 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 six (6) residents in care, of whom all were non-ambulatory. The facility’s license does not include endorsements for delayed-egress doors or secured perimeters, and none of these were present.

LPA, accompanied by Licensee’s staff, toured the interior and exterior of the facility and inspected all common areas and resident bedrooms. LPA interviewed multiple residents and multiple staff. LPA reviewed care records for all residents and personnel records for all active staff.

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.

[CONTINUED ON LIC 809-C]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2025
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
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: FAITH VILLA
FACILITY NUMBER: 374604697
VISIT DATE: 08/25/2025
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[CONTINUED FROM LIC 809]

The facility’s ambient internal temperature was complaint at 74 F. Where tested, hot water temperature at taps accessible to residents were all compliant: Kitchen Sink was 110.1 F, Bathroom #1 Sink was 109.2 F, and Bathroom #2 Sink was 109.4 F. Appliances to preserve perishable food were also compliant in temperature. 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.

There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Carbon monoxide detector, smoke detectors, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguisher had been serviced within the last twelve (12) months. The facility’s fireplace was screened, as required. No pools/bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Fire/disaster drills were performed at required intervals. There were reserve supplies of Personal Protective Equipment (PPE). Staff were trained on the both facility's written LIC610E Emergency Disaster Plan and PPE within the last twelve (12) months, as required. Licensee presented proof of current business liability insurance.

During records review, LPA observed, and manager interview confirmed: Licensee did not maintain written proof that 3 of 6 staff (S1, S2, and S3) had current/active First Aid Training. (Regulation requires all care staff to have first aid training from “persons qualified by such agencies as the American Red Cross.”) [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC809-D page). A Plan of Correction was jointly developed with the Licensee.

LPA also issued two (2) Technical Violations (TV), regarding a videoconferencing device dedicated for resident use and regarding knob protectors for the kitchen range (refer to the LIC9102-TV pages).

An exit interview was conducted with Licensees Mevyl Deguzman and Aries Deguzman, to whom a copy of this report, the LIC 809-D page, the LIC9102-TV pages, and the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/25/2025 02:29 PM - It Cannot Be Edited


Created By: Dang Nguyen On 08/25/2025 at 01:55 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: 08/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements – General: “(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not ensure that 3 of 6 staff (S1, S2, and S3) providing care received current training in first aid from persons qualified by such agencies as the American Red Cross. This posed a potential health risk to persons in care.
POC Due Date: 09/25/2025
Plan of Correction
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Licensee agreed to have S1, S2, and S3 each complete training on First Aid from an instructor qualified by such agencies as the American Red Cross. Licensee agreed to E-mail copies of their First Aid Certification cards 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2025


LIC809 (FAS) - (06/04)
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