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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604729
Report Date: 10/17/2024
Date Signed: 10/17/2024 01:40:17 PM

Document Has Been Signed on 10/17/2024 01:40 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:LA MESA ELDER CAREFACILITY NUMBER:
374604729
ADMINISTRATOR/
DIRECTOR:		RATHI, GAURAVFACILITY TYPE:
740
ADDRESS:7784 MELOTTE STREETTELEPHONE:
(619) 791-5495
CITY:SAN DIEGOSTATE: CAZIP CODE:
92119
CAPACITY: 6CENSUS: 6DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Caregiver Araceli MoraTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Caregiver Araceli Mora. Administrator Jenifer Sequeira arrived shortly after. According to the facility’s license, the facility has a maximum capacity of six residents, of whom all may be non-ambulatory and 1 may be bedridden.

LPA toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. .

Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in locked cabinet.



A pool is present with appropriate locked fence. Per Jenifer, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was present. First aid kit(s) were complete and readily accessible. Resident records reviewed had required documentation. Staff records reviewed contained required documentation.

Upon entry to the facility, LPA Strong observed pad lock and additional latch lock on the inside of the front door. Pad lock code is required to unlock top deadlock and a key is required to unlock top latch if used. An deficiency is being cited per California Code of Regulations along with an immediate civil penalty due to fire clearance violation.

An exit interview was conducted with Administrator, to whom a copy of this report LIC 809-D, LIC421IM, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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 10/17/2024 01:40 PM - It Cannot Be Edited


Created By: Iby Strong On 10/17/2024 at 11:31 AM
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: LA MESA ELDER CARE
FACILITY NUMBER: 374604729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above in 6 of 6 persons which poses an immediate safety risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee removed pad lock and latch lock during visit. POC has been cleared.
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:Simon Jacob
LICENSING EVALUATOR NAME:Iby Strong
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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