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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604941
Report Date: 12/09/2025
Date Signed: 12/09/2025 10:27:22 AM

Document Has Been Signed on 12/09/2025 10:27 AM - 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:CRISTOBAL WAY RCFEFACILITY NUMBER:
374604941
ADMINISTRATOR/
DIRECTOR:		MASE, DOMINIQUE JOHN OFACILITY TYPE:
740
ADDRESS:3369 CRISTOBAL WAYTELEPHONE:
(619) 405-3586
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 4DATE:
12/09/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Filemon Radurat, Caregiver &
Milagros "Mila" Postert , Administrator		TIME VISIT/
INSPECTION COMPLETED:
10:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management visit. LPA met with Filemon Radurat, Caregiver, and we discussed the purpose of the visit. Milagros "Mila" Postert , Administrator arrived during the visit.

On 11/25/2025, the Regional Office received a Title 17 Deficiencies/Corrective Action Plan regarding the facility. San Diego Regional Center (SDRC) staff noted on 11/24/2025 that clients medications were observed and locked, however, the cold refrigerator medications were not locked. The key was in the mini refrigerator, but staff were unable to lock it.

It was also observed by the SDRC Liaison the Fire Drill Log showed that a fire drill had occurred on 11/24/25. Among the staff and residents, the log also listed that administrator was present for the fire drill. Interviews revealed the Liaison asked and administrator indicated that they weren’t there for the fire drill. Later, this liaison interviewed one of the residents and they weren’t able to discuss what to do in a fire. According to this interview, the client indicated that they didn’t recall a fire drill earlier in the day. Interviews revealed the providers use verbal commands to call the fire drill.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Tiffany Holmes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2025
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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Document Has Been Signed on 12/09/2025 10:27 AM - It Cannot Be Edited


Created By: Tiffany Holmes On 12/03/2025 at 11:46 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: CRISTOBAL WAY RCFE
FACILITY NUMBER: 374604941

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/12/2025
Section Cited
CCR
87203

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87203 Fire Safety: “All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.” This requirement was not met, as evidenced by:
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During today’s visit, Licensee remedied the seven (7) non-working smoke alarms.

POC is completed and cleared.
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Based on SDRC observation, Licensee did not maintain the facility in continuous conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire. This posed an immediate safety risk to 4 of 4 residents (R1 through R4) in care.
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Type A
12/12/2025
Section Cited
HSC1569.311

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Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
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Licensee purchased two (2) new carbon monoxide detectors. POC is completed and cleared
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Based on observation, the licensee did not comply with the section cited above in not having any carbon monoxide detectors. This posed an immediate safety risk to 4 of 4 residents (R1 through R4) in care.
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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:
Tiffany Holmes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/09/2025 10:27 AM - It Cannot Be Edited


Created By: Tiffany Holmes On 12/03/2025 at 11:46 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: CRISTOBAL WAY RCFE
FACILITY NUMBER: 374604941

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2025
Section Cited
HSC
1569.695(c)

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H&S 1569.695 Emergency Plans (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 was not met as evidenced by:
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The fire drill form for the facility was filled out and the fire drill was performed on 12/07/2025
LPA obtained a copy of the fire drill. This POC is deemed completed and cleared.
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Based on records review, the facility did not have quarterly fire drills on file for the facility which posed a potential safety risk to 4 [R1, R2, R3 and R4] of 4 persons in care.
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Type B
12/26/2025
Section Cited
CCR87465(h)(2)

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Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication, this requirement was not met as evidenced by:
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Licensee has agreed to speak with all staff and enforce medications to be locked and at all times.
Licensee will submit a plan to ensure medications will be inaccessible to residents. Licensee will also provide training to all staff by an outside source. POC due date of 12/26/2025. POC documentation (training documents and sign in sheet) will be sent to CCL by POC due date by email.
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Based on review, the facility did not have refrigerated medications locked for 4 of 4 residents [R1, R2, R3& R4]. This posed a potential safety risk to persons in care.
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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:
Tiffany Holmes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: CRISTOBAL WAY RCFE
FACILITY NUMBER: 374604941
VISIT DATE: 12/09/2025
NARRATIVE
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Interviews with staff also revealed, that the home was currently lacking a working fire alarm.

Interviews with staff also revealed, that the home was currently lacking carbon monoxide dectectors.

During today's visit, LPA discussed the issues identified on the Title 17 Deficiencies/Corrective Action Plan. Plan of Corrections for the Title 17 Deficiencies were reviewed. As such, the applicable regulations will be cited for deficiencies observed by an outside agency.

During today's visit, the Title 17 deficiencies noted above, were observed to be corrected on this date except for one which requires training for staff, however, these applicable deficiencies are cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapters 1 and 6, and are noted on the attached LIC809-D. The Licensee was provided a copy of their appeal rights (LIC9058 03/22), and their authorized representative's signature on this form, acknowledges receipt of these rights. An exit interview was conducted and a copy of this report was provided at the conclusion of the visit
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Tiffany Holmes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC809 (FAS) - (06/04)
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