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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604839
Report Date: 09/05/2025
Date Signed: 09/05/2025 08:08:14 PM

Document Has Been Signed on 09/05/2025 08:08 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:CASA DE CASTRO IIIFACILITY NUMBER:
374604839
ADMINISTRATOR/
DIRECTOR:		CASTRO, CELESTE & CHERYLFACILITY TYPE:
740
ADDRESS:319 S SIENA STTELEPHONE:
(619) 857-6945
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 6CENSUS: 5DATE:
09/05/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:00 PM
MET WITH:Cheryl Castro, LicenseeTIME VISIT/
INSPECTION COMPLETED:
08:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced visit to conduct an investigation and in conjunction, conducted this case management visit due to deficiencies found during the investigation. LPA identified herself and was granted entry by Elizabeth Lim, caregiver. LPA stated the purpose of the visit and reviewed the basic elements of this visit with Licensee Cheryl Castro.

During the Department’s investigation of complaint control # 08-AS-20250827145528, there were additional discrepancies found, which are being addressed during today’s visit. During the investigation, which consisted of interviews with staff, and residents, and records review of relevant documents, the investigation uncovered that the facility was not providing medication as prescribed, there is insufficient staff to meet the resident’s needs, residents are unable to leave their bedrooms after 6:00 PM, a resident who needed incontinence assistance was malodorous, and resident had dirty bedsheets.

During today’s visit, LPA spoke with the residents (R2, R4, and R5), and staff #1 (S1) and staff #2 (S2) who confirmed that caregivers send residents to their room at 6:00 PM after their shift to rest for the night. According to interviews with residents and staff, S1 and S2 are the only caregivers who work at this facility and also reside at the facility. After review of records, it showed that S1 works at the facility from 6:00 AM – 12:00 PM and S2 works from 12:00 PM – 6:00 PM, which leaves the NOC shift unavailable. According to S1 and S2, they care for the resident after their shift if they require assistance throughout the night. Residents interviewed said they were not allowed out of their rooms after 6:00 PM but may yell for staff if they need assistance. During an interview of R3, LPA observed the resident to be malodorous of urine. LPA observed that the resident’s bedsheets were stained of dried fecal matter.

(Continuation on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Carmen Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2025
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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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: CASA DE CASTRO III
FACILITY NUMBER: 374604839
VISIT DATE: 09/05/2025
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(Continuation of LIC809)

According to staff, R3, had to be changed throughout the night because they had gone “poo poo.” While LPA spoke with the Licensee, they observed that the Medication Administration Records (MARs) had been compiled inside manila envelopes and LPA inquired how the staff are aware that they provide the medications to the residents. According to the Licensee, they write the medication timing on top of the bottle – either AM or PM or both. That is how staff know when the residents are to take the medications. LPA further inquired if they used the MARs and Licensee said no. LPA asked if bubble packs would be easier for staff and Licensee said that it would be more difficult for staff as there are too many packs to keep track of. LPA asked if they could demonstrate with one residents’ medication. When LPA opened two medications for R1 they found that medications were missing. There were two pill medications from one bottle missing and 5 pill medications from another bottle missing for R1 which LPA explained to the Licensee and counted in front of them.

Based on the information obtained during the investigation, there are deficiencies observed and being cited during this visit and may be found on the LIC809-D page of this report .

The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with licensee Cheryl Castro. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) were provided to licensee Castro at the conclusion of the visit. The signature below confirms the receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Carmen Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/19/2025 04:01 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/19/2025 02:47 PM


Created By: Carmen Lopez On 09/05/2025 at 05:52 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA DE CASTRO III
FACILITY NUMBER: 374604839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2025
Section Cited
CCR
87465(c)(2)

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87465 (c)(2) Incidental Medical and Dental Care: (2) Once ordered by the physician the medication is given according to the physician's directions..… this requirement was not met as evidence by:
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Licensee will be implementing the MAR system on a regular baisis and will send the updates to LPA via email by POC due date, 09/19/2025.
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Based on observation, staff did not provide medications as prescribed for R1, [1 of 5] residents in care which posed a potential health risk to 1 of 5 residents in care.
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This is an amended version to an original report delivered on 9/5/2025.
Type A
09/19/2025
Section Cited
CCR87411(a)

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87411 (a) Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.… this requirement was not met as evidence by:
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Licensee agreed to give an additional 2 hours to each caregiver for a total of 4 hours and provide LPA documentation by POC due date, 09/19/2025.
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Based on interviews, staff covered 2 shifts at the facility but the third shift was not being scheduled to be covered which posed a potential potential safety risk to 5 of 5 residents in care.
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This is an amended version to an original report delivered on 9/5/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:
Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2025 04:03 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/19/2025 02:48 PM


Created By: Carmen Lopez On 09/05/2025 at 05:53 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA DE CASTRO III
FACILITY NUMBER: 374604839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2025
Section Cited
CCR
87468.2(a)(6)

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87468.2 (a)(6) Additional Personal Rights of Residents in All Facilities: (6) To make choices concerning their daily lives in the facility.… this requirement was not met as evidence by:
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Licensee agreed to speak with residents and inform them that they will be able to leave their rooms after 6PM and document and submit their documentation to LPA by POC due date.
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Based on interviews with staff and residents, it was confirmed that residents are being sent to their rooms by 6:00 PM for 5 of 5 resident in care which posed a potential personal rights risk to 5 of 5 residents in care.
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This is an amended version to an original report delivered on 9/5/2025.
Type A
09/05/2025
Section Cited
CCR87625(b)(3)

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87625 (b)(3) Managed Incontinence: (3) Ensuring that incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence.… this requirement was not met as evidence by:
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Licensee had staff change R3 during the visit. This citation is deemed cleared during the visit. Licensee agreed to have R3 checked at least 5 times and changed as needed. Licensee will email LPA of the updates.
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Based on LPA observations and interviews, resident R3 was malodorous (of urine) during their interview, which posed a potential personal rights risk to 1 of 5 residents in care.
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This is an amended version to an original report delivered on 9/5/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:
Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 09/19/2025 04:05 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/19/2025 02:52 PM


Created By: Carmen Lopez On 09/05/2025 at 05:55 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA DE CASTRO III
FACILITY NUMBER: 374604839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/05/2025
Section Cited
CCR
87307(a)(3)(C)

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87307 (a)(3)(C) Personal Accommodations and Services: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited..… this requirement was not met as evidence by:
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Licensee had staff change the linens during LPA's visit. This citation was deemed cleared during the visit.
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Based on LPA observations, residents bedspread had fecal matter on top of R3s bed which posed a potential health risk to 1 of 5 residents in care.
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This is an amended version to an original report delivered on 9/5/2025.

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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.
Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:
Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2025


LIC809 (FAS) - (06/04)
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