374604791-7-30-2025-08-AS-DCOA-DK44Q2-20250730191736

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604791
Report Date: 07/30/2025
Date Signed: 07/30/2025 07:17:55 PM

Document Has Been Signed on 07/30/2025 07:17 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:	SIMA COURT RCFE		FACILITY NUMBER:	374604791
ADMINISTRATOR/ DIRECTOR:	MASE, DOMINIQUE JOHN O.		FACILITY TYPE:	740
ADDRESS:	10726 SIMA COURT		TELEPHONE:	(619) 405-3586
CITY:	SANTEE	STATE: CA	ZIP CODE:	92071
CAPACITY: 4		CENSUS: 2	DATE:	07/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:15 PM
MET WITH:	Licensee Dominique Mase		TIME VISIT/ INSPECTION COMPLETED:	06:00 PM

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced required annual visit. LPA was greeted by Caregiver Porcoincula, identified herself, and was granted entry into the facility. LPA then met with Licensee Dominique Mase who was informed the purpose of the visit was to ensure that the facility is in compliance with the California Code of Regulations, Title 22, Division 6.

During today's visit, LPA Correia conducted facility, staff, and client records reviews that were observed to be accurate and complete. The facility has current liability insurance and surety bond. Administrator certification was current, fire extinguishers were last inspected on 02/09/2025, smoke alarms and carbon monoxide detectors were present and operable.

LPA accompanied by Licensee Mase toured the facility inside and outside, client bedrooms were observed to be clean; required furnishings were present, and safeguards were present in the clients’ bathroom. Toilets were found to be in working order, lidded trash cans were present. Hot water temperature in client bathroom measured at 108.9 degrees F. The facility was found to be sanitary and in good repair. LPA did not observe any obstructions of pathways. The facility's ambient temperature was 77 degrees F during the visit. Hazardous and/or toxic chemicals were stored and secured in locked cabinets that are inaccessible to clients. Client medications were also centrally stored in locked cabinets. There was a first aid kit and manual present in the facility. The facility had sufficient space in which to conduct activities. No pools or bodies of water were observed near or on the premises. According to the Licensee, no firearms and/or ammunition present or will be stored in the facility. Sufficient and appropriate storage was present to store perishable and non-perishable food items. Required postings were present and posted in a visible area of the facility.

No deficiencies were observed or cited during today's post- licensing/annual inspection.

An exit interview was conducted with Licensee Dominique Mase to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/) were provided during the visit.

NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Debbie Correia
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025

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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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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