CALIFORNIA DEPARTMENT OF SOCIAL SERVICES …cdn.sandiegouniontrib.com/news/documents/2013/09/16/MH4.pdf · state of caufornia· health and human services agency california department

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY-

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

NO nCE OF CIVIL PENALTIES DUE

III Initial Invoice o Final Notice Date Sent ----------------INVOICE NO. _08_0_14_04 __ _ REGIONAL OR COUNTY OFFICE NUMBER 08

FACILITY NAME

MISSION HOME 4 PHYSICAL ADDRESS

2849 MELBOURNE DRIVE CITY

I STATE

SAN DIEGO CA MAILING ADDRESS

2849 MELBOURNE DRIVE CITY I STATE SAN DIEGO CA

LlCENSEE(S) OR UNLICENSED FACILITY OPERATOR

CURMAK. GUNNUR ADDRESS

2996 MISSION VILLAGE DR CITY ISTATE

SAN DIEGO CA

I ZIP CODE

92123

121P CODE

92123

l ZIP CODE

92123

'FiSCAL YEAR

2012/13 FACILITY TYPE

RCFE

I FACILITY NUMBER

374603043

-------

DATE L1C 422 SENT

05/08/2013 PENALTY PCA CODE

84037

On 04/09/2013 your facility was found to be in violation of one or more sections of the California Health and Safety Code. DATE

See attached LlC 421 series form. As a result, you were assessed the following amount:

(DATE)

Penalty Amount Originally Assessed: 04/09/2013 $ 150.00 (DATE)

Penalty Amount Amended: $ (DATE)

Pa'Lment Received: $

Balance Due: $ 150.00

Send a copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SE;RVICES. Please write your invoice and facilit number s on ur ch ck.

To: CIVIL PENALTY COORDINATOR

COMMUNITY CARE LICENSING DIVISION

7575 METROPOLITAN DRIVE SUITE 109

SAN DIEGO CA 92108

FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING:

• SEIZURE OF PERSONAL INCOME TAX REFUNDS

• LICENSE DENIAL, SUSPENSION, OR REVOCATION

• COURT ACTION

LlC 422 (91 11) (PUBLIC)

STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CIVIL PENALTY ASSESSMENT FACILITY NAME -------

Mission Home 4 FACILITY ADDRESS

2849 Melbourne Dr ~ ---STATE

San Diego CA LlCENSEE(S)/OPE~R:::;Aro;<:R;:;============-

Gunner Curmak

LICENSED FACILITY

I DArr--

04/09/2013

ZIP CODE l 92123 FACILITY . :

374603043 - --'-- - ' "

Civ~1 pe~alties can be assessed against any facility which fails to take corrective action within prescribed time periods, per California Health and Safety Code Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.58. You are hereby notified that a civil penalty has been assessed.

The above facility has been found in violation of the California Code of Regulations, Title 22, Divisions 6, and/or 12, Section(s) .-:---87<->:5""5,,,,5(,..al-) -:-:-_~~~::--_________ _______ ____ _ _ _______ _

and/or California Health and Safety Code, Division 2, Chapters 3, 3.01, 3.2, 3.4, and 3.5, and 3.6. Section(s) _ _ _____ ______ ________________ ___________ _

A Licensing Report (L1C 809 or L1C 9099) was issued on _____ -"0""3/LJ1~3~/2~0-'-'13"------ giving notice that failure to correct the above violation(s) would result in a civil penalty. DATE

o Because you failed to make the corrections specified on the LlC 809, a civil penalty of $ ______ is assessed for the period from through _ ______ _

DATE DATE o A civil penalty of $50 per violation per day, up to a maximum of $150 per violation per day will be assessed. This will continue until correction(s) is made to comply with the licensing laws, regulations, and approval of the California Department of Social Services or authorized licensing agency.

Because you repeated a violation of the same subsection within a 12-month period, an immediate civil penalty of $ 150 00 is assessed for the period from 04/09/2013 through 04/09/2013

DATE DATE

o All Facility Types Except Child Care Centers: Second citation within a 12 month period; an immediate civil penalty of $150 per violation; then $50 per day per violation until corrections are made.

o Child Care Centers Only: Second citation within a 12-month period; an immediate civil penalty of $150 per violation; then $150 per day per violation until corrections are made.

o Residential Care Facility for the Elderly (RCFE), Residential Care Facility for the Chronically III (RCF-CI): Third citation within a 12-month period; an immediate civil penalty of $1,000 per violation; then $100 per day per violation until corrections are made.

o Family Child Care Home (FCCH), Child Care Center (CCG), Community Care Facility (CCF): Third citation within 12-month period; an immediate civil penalty of $150 per violation; then $150 per day per violation until corrections are made.

o FCCH and CCC only: Second or subsequent violation for failure to allow parent or guardian to enter and inspect facility or for retaliation/discrimination stemming from a request to enter or lodge a complaint. A civil penalty of $50 per violation.

NAME OF LICENSING PROGRAM ANALYST

Kim Tang

SIGNATURE OF LICENSING PROGRAM ANALYST

Total Penalty Assessed $_15_0_._00 _____ _

YOU WILL RECEIVE AN INVOICE IN THE MAIL.

DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE

- - NAME OF FACILITY REPRESENTATIVEfTlTLE =

I Gunnur Curmak

~ SIGNATURE OF FACI~ITY REP ENTATIVE

J -.. -~ I

TITLE

Licensing Program Manager _-..1_

=---=

PAGE 1 OF2

STATE OF CAUFORNIA · HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE lICENSING DMSION

FACILITY EVALUATION REPORT CClD Regional Office, 7575 METROPOLITAN DR. 11109 SAN DIEGO, CA 92108

FACILITY NAME: MISSION HOME 4 ADMINISTRATOR:CURMAK, JOHN

FACILITY NUMBER: FACILITY TYPE:

374603043 740

(858) 569-0951 92123

04/09/2013 02:15 PM 03:15 PM

ADDRESS: 2849 MELBOURNE DRIVE TELEPHONE: CITY: SAN DIEGO STATE:CA

CENSUS: 3 UNANNOUNCED

ZIP CODE: CAPACITY: 6 DATE: TYPE OF VISIT: POC TIME BEGAN: MET WlTH: CURMAK, GUNNUR TIME COMPLETED:

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

NARRATIVE LPA Kim Tang made an unannounced visit to the facility for the purposes of a Plan of Correction (POC) visit, based upon the deficiencies cited in LlC form 809 0 on 03/1312013. Based upon this inspection , the LPA observed the following:

'Deficiency cited under Title 22 Regulation 87307(a)(2)(8) has been cleared. Licensee complied with the lerms of the POCo

'Deficiency cited under Title 22 Regulation 87307(d)(3)(A) has been cleared. Licensee complied with the terms of the POCo

A civil penalty has been assessed for one citation listed on the report dated 312012013. Citation number 87211(a)(1 )(0) was cited on November 15, 2012 and again on 03/2012013. You will receive a bill in the mail. Payment is due when billed. Payment must be made by a personal, business or cashier's check or money order made payable to the "California Department of SOCial Services" Please write the facility number and invoice number on your check and include a copy of your bill with the payment. You will find the invoice number on your bill. DO NOT SEND CASH.

An exit interview was conducted and a copy of report left with Gunnur Curmak

SUPERVISOR'S NAME: Caitlin Leeger

LICENSING EVALUATOR NAME: Kim Tang

TELEPHONE: (619) 767-2306

TELEPHONE: (619) 688-0108

LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2013

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/0912013

This report must be available at Child Care and Group Home facilities for public review for 3 years.

UC809 (FAS). (06104) Page: 1 011

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office 7575 METROPOLITAN DR. #109 SAN DIEGO, CA 92108

03/25/2013

MISSION HOME 4 374603043 2849 MELBOURNE SAN DIEGO, CA 92123

Letter of Deficiency Citations Cleared Dear Licensee,

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

The following defiCiencies, initially cited during a visit on 03/13/2013, have been cleared:

Section Cited: 87705(k)(3) Date Due: 03/27/2013 Plan of Correction: Licensee is to conduct a fire and earthquake drill at least once every three months and maintain a frill drill log. Licensee is to conduct a fire drill by POC date. Proof of fire drill is to be submitted by POC date 03/14/2013

Section Cited: 87411

Plan of Correction: A copy of the current first aid card for S 1 will be sent to eel by poe date.

Section Cited: 87468(b)

Plan of Correction: Licensee shalll ensure that all the personal rights forms are signed and dated. R- 2's personal rights form shall be completed and submitted to Licensing by poe date.

Section Cited: 87506(a)

Plan of Correction: Licensee shall ensure that all consent form are signed for all residents, provide copy of completed consent forms for R-1, R-2 and R-3 by poe date.



Corrections: Licensing received a statement from licensee that Fire drill was conducted on 3118113

Date Due: 03/27/2013

Corrections: Licensing received the certificate of completion for First Aid. Course was completed on 3/20113 . Certificate was good for 2 years.

Date Due: 03/27/2013

Clearance Date: 03/20/2013


Corrections: Clearance Date: Licensing received completed Personal 03/20/2013 Rights form for R-2

Date Due: 03/27/2013

Corrections: Licensing received consent forms for R-1, R-2 and R-3


TELEPHONE: (619) 688-0108

DATE: 03/25/2013

This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared pac Letter (FAS) _ (04105) Page: 1 of 1


CClD Regional Office 7575 METROPOLITAN DR. #109 SAN DIEGO, CA 92108

04/09/2013




The following deficiencies, initially cited during a visit on 03/13/2013, have been cleared:

Section Cited: 87505(c)(3 Date Due: 03/27/2013 Plan of Correction: Corrections: Clearance Date:

03/25/2013 Licensee will ensure direct care staff #3 & staff # have the dementia Proof of in-services training received training. Licensee will have the training complete by POC date for staff-3 and staff-4

Section Cited: 87411(c) Plan of Correction: Administrator must provide and submit proof of Staff #3 & Staff #4 annual training . Which include 4 hours med training and 4 hours general training to Licensing by POC date.

Section Cited: 87307(a)(2)(8) Plan of Correction: Licensee shall ensure no staff sleep in common areas. All live-in staff required a room & a bed. Licensee shall provide proof of sleeping quarters for live-in staff by POC date.



Date Due: 03/27/2013 Corrections: Clearance Date: Licensee provided training log for staff 04/02/2013 #3 & #4.

Date Due: 03/27/2013 Corrections: Cleared 8y Visit


TELEPHONE: (619) 688-0108

DATE: 04/09/2013

This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS) _ (04105) Page: 1 of 1



03/25/2013




The following defiCiencies, initially cited during a visit on 03/13/2013, have been cleared:

Section Cited: 87705 Plan of Correction: Licensee shall ensure that ranges/stoves are inaccessible to residents. Staff removed all knobs from range and oven. The licensee and the Administrator shall read regulation 88705- Care of Persons with Dementia and send a statement to their LPA stating they read the regulations and will abide by the regulations in the future. Send statement by POC date.

Section Cited: 87465 Plan of Correction: Staff locked up all diabetic supplies during today's visit. The Licensee shall ensure that the facility is complying with Title 22 Regulations at all times. POC corrected during today's visit.

Section Cited: 87465(h)(2) Plan of Correction: The licensee shall ensure all medications are locked up. Staff discarded the medications, cleaning product and aftershaves, staff locked up the mouthwash during today's visit. Medications belong to prior resident. The Licensee shall ensure that the facility is complying with Title 22 Regulations at all times.



Date Due: 03/27/2013 Corrections: Received statement from licensee

Date Due: 03/27/2013


Corrections: Clearance Date: poe cleared during visit. Staff locked 03/14/2013 up all diabetic supplies during visit.

Date Due: 03/27/2013

Corrections: Clearance Date: poe cleared during visit. Staff discard 03/14/2013 products and locked up mouthwash.

TELEPHONE: (619) 688-0108

DATE: 03/25/2013

This report must be available at Child Care and Group Home facilities for public review for 3 years, Cleared POC LeHer (FAS) _ (04105) Page: 1 or 1

STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office 7575 METROPOLITAN DR. #109 SAN DIEGO, CA 92108

03/13/2013





Section Cited: 87705(f)(2) Date Due: 03/27/2013 Plan of Correction: Corrections: Clearance Date: The sIaff locked up the laundry room which stored the toxins. Cleared during visit. Staff locked the 03/13/2013 cleaning supplies during today visit. The Licensee shall ensure that laundry room . the facility is complying with Title 22 Regulations at all times.

poe cleared during today's visit.

Section Cited: 87705 (f)(2 Plan of Correction: Slaff removed their personal hygiene items and locked up during today's visil The Licensee shall ensure that the facility is complying with Title 22 Regulations at all times.

poe cleared during today's visit.

Section Cited: 87303(a) Plan of Correction: The rlCef1see shall ensure these cushions are repaired or replaced with proof to licensing by poe date.

POC cleared today 's during visit on 3113113. Licensee aD replaced worn-out cushions.



r}/v('

Date Due: 03/27/2013 Corrections: Staff removed personal hygiene items from resident room and locked up items during visit.

Date Due: 03/27/2013 Corrections: LPA observed new cushions on

03/12113



TELEPHONE: (619) 688-0108

DATE: 03/13/2013

This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS) • (04105) Page: 1 of 1



04/09/2013


Letter of Deficiency Citations Cleared

Dear Licensee,

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES , COMMUNITY CARE LICENSING DIVISION

~,.,~ .. " .' ,

!!S.!. ... .


Section Cited: 87307 (dX3XA) Plan of Correction: Licensee shall place nonskid rug in each of the bathroom to prevent fall during bath time. Licensee shall provide proof of purchased and pictures of nonskid rugs \0 Licensing by poe.

Section Cited: 87457 Plan of Correction: Licensee shall ensure that a proper pre-appraisal is done prior to admission and a current needs and services plan shall be on file at all times for all residents. Licensee shall submit a Needs and Service Plan for R-1 and R-2 by poe date.



I~

Date Due: 03/27/2013 Corrections: Cleared By Visit

Date Due: 03/27/2013


Corrections: Clearance Date: Licensing received Current Needs and 03/20/2013 Services plan for R-1 & R-2.

TELEPHONE: (619) 688-0108

DATE: 04109/2013

This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS) - (04105) Page: 1 of 1

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Dear Licensee,


The following deficiencies, initially cited during a visit on 03/13/2013, have been cleared :

Section Cited: 87211(a)(1)(D) Plan of Correction: Licensee shall submit Unusual Incident Report to Licensing on all incident reports are filed per regulation. Licensee and Administrator shall read regulation 87211 and send to Licensing stating they read the regulations and shall abide by the regulations in the future. Send statement by POC date.



'I~

Date Due: 03/27/2013 Corrections: Received statement from licensee.


TELEPHONE: (619) 688-0108

DATE: 03/25/2013


STATE OF CALIFORNIA - HEALTH AND HUMAN SER\ilCES AGENCY

FACILITY EVALUATION REPORT

FACILITY NAME: MISSION HOME 4 ADMINISTRATOR: CURMAK, JOHN ADDRESS: 2849 MELBOURNE DRIVE CITY: SAN DIEGO CAPACITY: 6 TYPE OF VISIT: Case Management MET WITH: Rosa Martinez

CAUFORNIA OEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING OMSION

CCLD Reglofl~1 Offi';;(f, 1615 METROPOLITAN OR. #109 SAN DIEGO, CA tf2.1 08

FACILITY NUMBER: FACILITY TYPE: TELEPHONE:

STATE:CA CENSUS: 3 UNANNOUNCED

ZIP CODE: DATE: TIME BEGAN:

374603043 740

(858) 569-0951 92123

0311312013 0845 AM mOOAM TIME COMPLETED:

NARRATIVE 1 2 3 4

Licensing Program Analyst (LPA) Kim Tang conducted an unannounced case management annual continuation visit to finalize visit commenced on 03112112013. LPA was granted entry Into facility and met with live-in caregiver Rosa Martine;;: .

5 6 7 8 9 10 11 12 13 14 15 16 17 18 : 19 20 21 . 22 i

23 !

24· 25

On 0311212013 LPA conducted an annual random visit; defiCiencies were observed and cited on this day. due to time constraints LPA was unable to complete the entire citation. LPA was unable to provide a copy of corresponding L1C 8090's on this date.

During today's visit, LPA issued and provided a copy of L1C 8090's Appeal rights were provided.

An exit interview was conducted. This report was discussed and a copy was provided to Rosa Martinez..

NOTES: L1C 8090 RECORDED ON 3/12/13 ARE NUll AND VOID. LICENSEE DID NOT RECEIVE A COpy OF 8090 RECORDED ON 3/1212013.

SUPERVISOR'S NAME: Caitiin Leeger TELEPHONE: (619) 767-2306

TELEPHONE: (619) 688-0108 LICENSING EVALUATOR NAME: Kim Tang


~A.J]. DATE: 0311312013

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


~lIlw DATE: 03/13/2013


L!Ce:09 (FAS)· (06/04) Paga: 1 of 7

STATE OF CALIFORNIA - HEAL TH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

FACILITY NAME: MISSION HOME 4

DEFICIENCY INFORMATION FOR THIS PAGE:

Deficiency Type POC Due Date 1 DEFICIENCIES Section Number

1 Care of Persons with Dementia: Fire and Type B 2 earthquake drills shall be conducted at least once

03/27/2013 3 every three months on each shift and shall include,

Section Cited 4 at a minimum, all direct care staff. lPA unable to 5 verify last fire drill or provide a fire drill log.

87705(k)(3) 6 7

1 Personnel Requirements-General. Type B 2 Staff shall receive first aid training from persons

03/27/2013 3 qualified by such agencies as the American Red

Section Cited 4 Cross. 5 -S1 does not have a current first aid card.

87411 6 7

1 Personal Rights . At admission, each resident and Type B 2 his/her responsible person shall be given a list of

03/27/2013 3 the personal rights of residents and a signed copy

Section Cited 4 of these rights shall be placed in the resident's 5 record. lPA observed there was no Personal Right

87468(b) 6 form signed for in R-2 7

1 Resident Records. A separate, complete , and

Type B 2 current record shall be maintained for each

03/27/2013 3 resident in the facility, readily available to facility 4 staff and to licensing agency staff and shall

Section Cited 5 contained specified information. lPA observed that 87506(a) 6 there was no signed medical consent form for

7 R-1 ,R-2 and R-3 .

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7


CClD Rogional Office, 7575 METROPOLITAN DR. #109 SAN DIEGO, CA 92108

FACILITY NUMBER: 374603043 VISIT DATE: 03/13/2013

PLAN OF CORRECTIONS(POCs)

Licensee is to conduct a fire and earthquake drill at least once every three months and maintain a frill drill log. Licensee is to conduct a fire drill by POC date. Proof of fire drill is to be submitted by POC date 03/14/2013

A copy of the current first aid card for S1 will be sent to CCl by POC date.

Licensee shalll ensure that all the personal rights forms are signed and dated. R- 2's personal rights form shall be completed and submitted to licensing by POC date.

licensee shall ensure that all consent form are signed for all residents, provide copy of completed consent forms for R-1, R-2 and R-3 by POC date.

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: Caitlin Leeger TELEPHONE: (619) 767-2306

LICENSING EVALUATOR NAME: Kim Tang TELEPHONE: (619) 688-0108


L ~ DATE, 0311212013

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


DATE: 03/12/2013

llC809 (FAS) - (06/04) Pago: 5 of 7

STATE OF CALIFORNIA· HEALTH ANO HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVlSl0N

FACILITY EVALUATION REPORT (Cont) CClO Rogional Office, 1'[;75 METROPOLITAN DR. #Wi! SAN DIEGO, CA92iOO

FACILITY NAME: MISSION HOME 4 DEFICIENCY INFORMATION FOR THIS PAGE:

FACILITY NUMBER: 374503043 VISIT DATE: 03/1312013

Deficiency Type POC Due Date I Section Number

Type B 03127120",3

Section Cited

8n05

Type B 03127/2013

Section Cited 87465

Type B 03127/2013

Section Cited 87465(h)(2)

DEFICIENCIES PLAN OF CORRECTIONS(POCs)

1 Care of Persons with Dementia. Ranges, heaters, 1 Licensee shall ensure that ranges/stoves are 2 wood stoves, inserts and other hating devices shall 2 inaccessible to residents, Staff removed at! knobs 3 be made inaccessible to residents. LPA observed 3 from range and oven. The licensee and the 4 that ranges' knobs were accessible to residents. 4 Administrator shall read regulation 88705- Care of 5 The facility has dementia residents 5 Persons with Dementia and send a statement to 6 6 their tPA stating they read the regulations and wit! 7 7 abide by the regulations in the futUre. Send

Incidental Medical and Dental Care Services. 1 Centrally stored medIcations shaH be kept fn a safe i 2 locked pJace that IS not accessible to persons other 2 3 than employees (esponsib!e for the superviSion of :3 4 the medication. LPA observed 4 bOxes of U!tiJet 4 5 Lancets sterile tip, 2 boxes of Glucose testing and 5 6 3 boxes of twist lancets (diabetic supptJes) s.:tting 6 7 on the floor of the family room. 7

Incidental Medical and Dental Care Services. 1 Centrally stored medications shalf be kept in a safe :2 locked pJace that !s not accessible to persons other 2 3 than employees responsible for the supervision of 3 4 the medlcation. 4 5 5 6 6 7 7

8 LPA observed tubes of Derma Gran BC- Perne! 8 9 Protectant, Calmoseptiine Oitment and CaYilon 9 10 skrn cleaning products, and 2 bottle of aftershaves 10 ,11 and bottle of mouthwash iii bathrooms, 11 12 12

11;1 ;;.

statement by poe d.te.

Staff locked up all diabetic supplies during today's viSit The Licensee shall ensure that the facility is complying with Titie 22 Regulations at all times. POC corrected during today's visit

The licensee shall ensure all medications are locked up. Staff dis~rded the medications, cleaning product and aftershaves, staff locked up the mouthwash during today's visit Medications belong to pfior resident The Licensee shall ensure that the facllity is complying with Title 22 Regu lations at all times.

Failure to correct the ciled deficiency!,e.), on or before the Plan of Correction (POC) due dale, may resutt in a civil penalty assessment. SUPERVISOR'S NAME: Caillin Leege, TELEPHONE: (619) 767-2306


·UCEN\~IGNATURE:

TELEPHONE: (619) 688-0108

DATE: 03/1212013

I acknowledge receipt of this form and understand··my appeal rights a$ explained and received~. _ ..

DATE: 0311212013

STATE OF CALIFORNIA - HEALTH ANO HUMAN SERVICES AGENCY



Deficiency Type POC Due Oate I DEFICIENCIES Section Number

1 Care of Persons with Dementia. The following

Type B 2 items sha ll be made inaccessible to residents with

3 dementia: Over-the-counter medication. nutritional 03/27/20 13 4 supplements or vitamins, alcohol, cigarettes, and

Sec tion Ci ted S toxic substances such as certa in plants , gardening

8770Sm(2) 6 supplies, cleaning supplies and disinfectants.

7 During the inspection

8 , LPA observed unlocked laundry room wh ich 9 stored aU cleaning chemicals. The facility has 10 dementia res idents. 11 12 13 14

1 Care of Persons with Dementia -

Type B 2 LPA observed staff has their personal hygiene

0312712013 3 items in R# 1 bathroom (which R# 1 has access

Section Cited 4 to). R# 1 has dementia. 5

87705 m (2 6 7

1 Maintenance and Operation . The facility shall be

Type B 2 clean, safe, sanitary and in good repa ir at all times.

03/2712013 3 LPA observed cushions on outdoor furniture are in 4 despair Section Cited 5

87303(0) 6 7

1 2 3 4 S 6 7

8 9 10 11 12 13 14

1 2 3 4 5 6 7

1 2 3 4 5 6 7

CALIFORNIA OEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

CClO ReglOflai Office, 7$7$ METROPOLITAN OR. '109 SAN DIEGO, CA 92101

FACILITY NUMBER: 374603043 VISIT DATE· 03/13/2013

PLAN OF CORRECTlONS(POCs)

The staff locked up the laundry room which stored the tox;ins , cleaning supplies during today visil. The Licensee shall ensure that the racility is complying with Title 22 Regulations al all times.

POC cleared during today's vis it.

Staff removed their personal hygiene items and locked up during today's visi t. The Licensee shan ensure that the facility is complying with Title 22 Regu lations at all times.

POC cleared during today's visit.

The licensee shan ensure these cushions are repaired or replaced with proof to licensing by POC date.

POC cleared today 's during visit on 3/13/13. Licensee all rep laced worn-out cushions.




TELEPHONE: (619) 688-0108

{~ DATE: 03/12/2013

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


~ (6)~~ DATE: 03/12/2013

LlC809 (FAS) - (08104) Pag8; 3 of7




DEFICIENCY INFORMATION FOR THIS PAGE:

Deficiency Type POC Due Date 1 DEFICIENCIES Section Number

1 Personal Accommodations and Services: all Type B 2 persons shall be protected against hazards within

03/27/2013 3 the facility through provision of the following:

Section Cited 4 Protective devices such as nonskid material on 5 rugs. LPA observed there was no nonskid rug in

87307 (d)(3)(A). 6 each of the bathroom. 7

8 All Three (3) bathrooms flooring have a smooth 9 glossy titles, which may be hazardous when 10 residents have their bath. 11 12 13 14

1 PRE-ADMISSION APPRAISAL: Prior to admission Type B 2 a determination of the prospective resident's

03/27/2013 3 suitability for admission shall be completed and 4 shall include an appraisal of hislher individual Section Cited 5 service needs in comparison with the admission

87457 6 criteria specified in Section 87455, 7

8 Acceptance and Retention Limitations. LPA 9 reviewed R-1 and R-2 records and found that there 10 was not a pre-appraisal or a current needs and 11 services plan for review 12 13 14

1 2 3 4 5 6 7

8 9 10 11 12 13 14

1 2 3 4 5 6 7

8 9 10 11 12 13 14


CCLD Regional Office, 7575 METROPOLITAN DR. #109 SAN DIEGO, CA 92108



Licensee shall place nonskid rug in each of the bathroom to prevent fall during bath time. Licensee shall provide proof of purchased and pictures of nonskid rugs to Licensing by POCo

Licensee shall ensure that a proper pre-appraisal is done prior to admission and a current needs and services plan shall be on file at all times for all residents. Licensee shall submit a Needs and Service Plan for R-1 and R-2 by POC date.

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: Caitlin Leeger TELEPHONE: (619) 767-2306



DATE: 03/12/2013

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


~m~ DATE: 03/12/2013

LlC809 (FAS) - (06/04) Page: 2 of 7

STATE OF CALIFORNIA - HEALTH ANO HUMAN SERVICES AGENCY



Deficiency Type POC Due Date I DEFICIENCIES Section Number

1 Reporting Requirements . The licensee shall send

Type B 2 a written report, within seven days, to the licensing

03/2712013 3 agency and the person responsible for the resident

Section Cited 4 when any incident occurs which threatens the 5 welfare , safety or health of an y resident. LPA found

87211 (a)(1 )(D) 6 discharge instructions for the following 7

8 incidents fro m th e hospital : On 12/2112011 for

9 metacarpal fra cture . On 1212112011 R- 1

10 experienced TIA and was taken to the hospita l .

11 On 02/07.2012 R·1 tell and was taken to the

12 hospital. The licensee did not report any of the

13 above incidents to Licensing.

14

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

8 9 10 11 12 13 14

1 2 3 4 5 6 7

1 2 3 4 5 6 7

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE liCENSING OIVlSION

CClD Regional Office, 7675 METROPOLITAN OR. 1111 09 SAN DIEGO, CA 92108



Licensee shall submit Unusual Incident Report to Licensing on all incident reports are filed per reg ulation . Licensee and Administrator shall read regul ation 87211 and send to Ucensing stating they read the regulations and shall abide by the regulations in the future . Send statement by pac date .

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: Caitlin Leeger TELEPHONE: (619) 767-2306



DATE: 03/13/2013



(~ A) DATE: 03/13/2013

l 1C809 (FAS) - (08104)

STATE OF CALIFORNIA · HEALTH AND HUMAN SERIltCES AGENCY


FACILITY NAME: MISSION HOME 4 ADMINISTRATOR: CURMAK, JOHN ADDRESS: 2849 MELBOURNE DRIVE CITY: SAN DIEGO CAPACITY: 6 TYPE OF VISIT: Case Management MET WITH: Gunnur Curmak

CALIFORNIA DEPARTMENT OF socrAL SERVICES COMMUNITY CARE LICENSING DIVISION

CCLD Regional omce, 1515 METROPOLITAN DR. '109 SAN DIEGO. CA 92108

FACILITY NUMBER: FACILITY TYPE: TELEPHONE:

STATE:CA CENSUS: 3 UNANNOUNCED

ZIP CODE: DATE: TIME BEGAN:

374603043 740

(858) 569-0951 92123

03/12/2013 10:15 AM 05 :00 PM TIME COMPLETED:

NARRATIVE 1 Licensing Program Analysts (LPA) Kim Tang conducted a Case Management visit on today's date , at the 2 above referenced facility . LPA was greeted and allowed entry into the facility by live-in caregiver Rosa 3 Martinez. The Administrator Gunnur Curmak arrived in ten (10) minutes . LPA stated purpose of today's visit, 4 i.e. to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California 5 Code of Regulations, Title 22, Division 6. 6 7 FACILITY'S PROFILE: Non-Ambulatory: 6 . 8 INSPECTION : LPA, accompanied by Ms. Rosa Martinez, conducted a general overall inspection, which 9 included, but was not limited to Ihe following: 10 Interior: checked the property against fire and paniC violations; capacity; no firearms and ammunition, 11 facility's temperature; indoor passageways; hot water temperature measured al 118 degrees F . Presence of 12 grab bars for each toilet, bathtub and shower; No non-skid mats found in the bathrooms; diet quality and 13 quantity necessary to meet resident's needs; nonperishable foods and perishable supply; ; items that could 14 constitute a danger are properly stored. 15 16 LPA requested and reviewed facility's records to ensure: staff have received required training; criminal record 17 clearance for all required persons; first aid training for all required persons; medical assessment for residents; 18 dementia training requirements, if applicable; emergency disaster plan; certified administrator; special 19 dementia care in plan of operation if applicable; LPA reviewed: medications and medication records. 20 LPA briefly interviewed and observed residents and slaff. 21 Exterior: All walkways are cleared of obstruction and window screens are intact. 22 The following deficiencies are cited from the California Code of Regulations, Title 22, Division 6, Chapter 8: 23 See 809D. An exit Interview was held , appeal rights discussed, and copies of the report were issued. 24 25




TELEPHONE: (619) 767-2306

TELEPHONE: (619) 688-0108

DATE: 03/12/2013

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


K~ n1lY1Tl~~ DATE: 03/12/2013

This report must be available at Child Care and Group Home facilities for public review for 3 years,

LlC809 (FAS) . (06104) Page: 1 of 4

STATE OF CALIFORNIA · HEALTH AND HUMAN SERVICES AGENCY



Deficiency Type POC Due Date f DEFICIENCIES Section Number

1 CARE OF PERSONS WITH DEMENTIA - 1

Type A 2 The facility has not conducted the quarterly fire 2

03/13/2013 3 drills for dementia residents . The last fire dnll was 3

Section Cited 4 conducted on 04111 12012. 4 5 5

87705 6 6 7 7

1 CARE OF PERSONS WITH DEMENTIA- 1

Type A 2 During the inspection. LPA observed unlocked 2

0311312013 3 laundry room which stored all cleaning chemicals . 3 4 The facility has dementia residents. 4

Section Cited 5 5 87705 6 6

7 7

1 Incidental Medical and Dental Care Services. 1 2 Centrally stored medications shall be kept in a safe 2

Type A 3 locked place that is not accessible to persons other 3

0311312013 4 than employees responsible for the supervision of 4 Section Cited 5 the medication . LPA observed 4 boxes of Vltile! 5

87465 6 Lancets (needles) sterile tip, 2 boxes of Glucose 6 7 testing and 3 boxes of twist lancets sitting on the 7

floor of the livingtoom.

1 Care of Persons with Dementia - 1

Type A 2 LPA observed staffs has their personal hygiene 2

0311312013 3 items in the resident's bathroom (which residents 3 4 have access to) unlocked. The facility has 4

Section Cited 5 dementia residents. 5 87705 6 6

7 7

CAL.IFORNIA DEPARTMENT OF SOCIAL. SERVICES COMMUNITY CARE LICENSING DIVISION

CClD Regional Office, 7575 METROPOL.ITAN DR 11'109 SAN DIEGO. CA 92108


PLAN OF CORRECTlONS(POCs)

The Licensee shall ensure that the quarterly fire drills for dementia residents are conducted as required per Title 22 by loday (0311 312013). The proof shall be submitted to the licensing office by 02/15/2013, to the attention of LPA Kim Tang

The staff locked up the laundry room which stored the taxies, cleaning supplies during today visit. The Licensee shall ensure that the facility is complying with Title 22 Regulations at all times.

Staff locked up all diabetic supplies during today's visit. POC corrected.The Licensee shalt ensure that the facility is complying with Tille 22 Regulations at all times .

Staff removed their personal hygiene items and locked up dunng today 's visit. .The Licensee shall enSUle that the facility is complying with Title 22 Regulations at all limes.




TELEPHONE: (619) 688-0108

DATE: 03/12/2013



DATE: 03/12/2013

L.IC809 (FAS) - (06104) P.ge: 20f 4

STATE OF CALIFORNIA • HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (ContI


Deficiency Type poe Due Date 1 DEFICIENCIES Section Number

ncidental Medical and Dental Care Services. 1 Centrally stored medications shall be kept in a safe

Type A 2 locked place that is not accessible to persons other

03/13/2013 3 than employees responsible for the supervision of

Section Cited 4 the medication. LPA observed tubes of Derma 5 Gran BC- Pernel Protectant, Calmoseptiine

87465(h)(2) 6 Oilment and Cavilon skin cleaning products, and 2 7 bottle of aftershaves and bottle of mouthwash in

bathrooms.

1 Care of Persons with Dementia. Ranges, heaters, Type A 2 wood stoves, inserts and other hating devices shall

03/1412013 3 be made inaccessible to residents. LPA observed

Section Cited 4 that ranges' knobs are accessible to residents. 5 The facility has dementia residents.

87705(d) 6 7

8 9 10 11 12 13 14

1 2

03/26/2013 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

8 9 10 11 12 13 14

1 2 3 4 5 6 7


CelO Regional OffIce, 7575 METROPOLITAN DR. .109 SAN DIEGO, CA 92106



The licensee shall ensured all medication are locked up. Staff discarded the medications, cleaning product and aftershaves, staff locked up the mouthwash during loday's visit. Medications belongs to prior resident. The Licensee shall ensure that the facility is complying with Title 22 Regulations al all limes.

Licensee shall ensured that ranges/stoves are inaccessible to residents. Staff removed all knobs from range and oven. The licensee and the Administrator shall read regulation 88705- Care of Persons with Dementia and send a statement 10 their LPA

staling they read the regulations and will abide by the regulations in the future. Send statement by poe date.

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: Caitlin leeger TELEPHONE: (619) 767-2306



DATE: 03/12/2013



DATE: 03/12/2013

UC809 (FAS) - (06104) Page: 3 ot <I




NARRATIVE

CALIFORNLA DEPARTMENT OF SOCLAL SERVICES COMMUNITY CARE LICENSING DIVISION

CelO Regional Office, 7575 METROPOLITAN DR. #109 SAN CIEGO, CA 92108


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

Due to time constraints LPA was unable to complete the entire report Therefore, LPA will return to facility in the near future to complete the citations. Citations be issued at the completion of the annual inspection




/~

TELEPHONE: (619) 767-2306

TELEPHONE: (619) 688-0108

DATE: 03/12/201 3



111 r ai1JI1At DATE: 03/12/2013

LlC809 (FAS) - (06104) Page: 4 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENC' CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CIVIL PENALTY LEDGER

INVOICE NO.,_0_80_1_32_9 _________ _ REGIONAL OFFICE NliMBER_08 __ _

FACILITY NAME FISCAL YEAR DATE LlC 422 SENT

MISSION HOME 4 2012/13 12128/2012 FACILITY ADDRESS FACILITY TYPE FACILITY PCA CODE

2849 MELBOURNE DRIVE RCFE 84037 CITY STATE ZIP CODE

SAN DIEGO CA 92123

LlCENSEE(S) OR UNLICENSED FACILITY OPERATOR I FACILITY NUMBER

I CURMAK,GUNNUR 374603043 ADDRESS

2996 MISSION VILLAGE DR CITY STATE ZIP CODE

SAN DIEGO CA 92123

DATE AMOUNT CUMULATIVE BALANCE Original Invoice Amount Assessed

12106/2012 $150.00 $150.00

Civil Penalty Amended Amount



Sent to Central Operations Branch

Payment 01/07/2013 $150.00 $0.00

Payment

Payment

Payment

Payment

COMMENTS: Paid in full on 01/07/2013 with check #4036 dated 01/03/2013, remitter Mission Home.

LlC 422A (10/11)

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENC) CAUFORNIA DEPARTMENT OF SOCiAl SERVICES

NOTICE OF CIVIL PENALTIES DUE

III Initial Invoice o Final Notice Date Sent ___ _____ _

INVOICE NO. 0801328 REGIONAL OR COUNTY OFFICE NUMBER_08~~ __

FACILITY NAME


2849 MELBOURNE DRIVE CITY I STATE


2849 MELBOURNE DRIVE CITY i STATE SAN DIEGO CA


CURMAK, GUNNUR ADDRESS

2996 MISSION VILLAGE DR CITY l STATE

SAN DIEGO CA

IZIP CODE

92123

iZIPCODE

92123

l ZIP CODE

92123

FISCAL YEAR

2012113

FACILITY TYPE

RCFE

I FACILITY NUMBER

374603043

SUPERVISOR APPROVAL

TITLE

DATE LlC 422 SENT


84037

I DATE


See attached L1C 421 series form. As a result, you were assessed the following amount:

(DATE)

Penalty Amount Oriqinally Assessed: 12106/2012 $ 150.00 (DATE)

Penalty Amount Amended: $ (DATE)

Payment Received: $


Send a copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number(s) on your check.




SAN DIEGO CA 92108

FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OFTHE FOLLOWING:



• COURT ACTION

LlC 422 (9/11) (PUBLIC)

STATE OF CALIFORNIA -~LTH AI'IO I«lIIIAfIt SERVI6ES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

...-..... CIVIL PENALTY ASSESSl ~NT --IMMEDIATE $150

FACILITY NAME

Mission Home 4 FACILITY ADDRESS

2849 Melbourne Drive lICENSEE(S)

Gunnur Curmak

CITY

San Diego

DATE

12/06/2012 STATE ZIP CODE

CA 92123

FACILITY I/:

374603043

A Licensing Report (LiC 809 or LlC 9099) was issued on _1_1/_1_5/_2_01_2 _____ giving notice that your facility has been found in DATE

violation of one or more requirements for which an immediate civil penalty is warranted in accordance with one or more of the following California Health and Safety Code Sections: 1548, 1568.0822, 1569.49, 1596.99 and 1597.58.

You are hereby notified that an immediate civil penalty of $150 per violation followed by $150 per day per violation until corrected is assessed for the period of 11/15/2012 through 11/15/2012 for the following violations:

DATE DATE

fll Violations which result in injury, sickness or death of a client in care. (Does not apply to Residential Care Facilities for the Chronically III or Foster Family Homes.)

D Fire clearance violations (Does not apply to Family Child Care Homes.)

D Absence of supervision

D Accessible bodies of water

D Accessible firearms, ammunition, or both

D licensing agent refused entry to a facility or any part of a facility

D The presence of an excluded person on the premises

Total # of (Per Day) Violations:

Total Penalty Assessed



NAME OF LICENSING PROGRAM ANALYST LICENSING PROGRAM ANALYST

Lisa Quinlivan

NAME OF FACILITY REPRESENTATIVElTfTl£ FACILITY REPRESENTATIVE

n~~ e.v.~~ SUPERVISOR REVIEW/SIGNATURE (FOR INTERNAL USE ONLy)

LlC 42 1C (7111)

DATE

X $150 $ 150.00

1210612012

DATE

12106/2012

DATE

PAGE 1 OF 2

5 TATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENC~ CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CIVIL PENALTY LEDGER

INVOICE NO._o_8o_1_32_8 _________ _ REGIONAL OFFICE NUMBER _0_8 __ _

l -------

FISCAL YEAR DATE lIC 422 SENT

2012/13 12/28/2012 FACILI TY TYPE FACILITY PCA CODE

I FACILITY NAME

I MISSION HOME 4 ~LlTY ADDRESS

i 2849 MELBOURNE DRIVE RCFE 84037 ~~-------------------------=~--------------~~~ CITY STATE ZIP CODE

SAN DIEGO CA 92123

I FACILITY NUMBER

374603043

I LlCENSEE(S) OR UNLICENSED FACILITY OPERATOR

CURMAK, GUNNUR ADDR ESS

2996 MISSION VILLAGE DR

SAN DIEGO

STATE ZIP CODE I

CA 92123

CITY

DATE AMOUNT CUMULATIVE BALANCE I

12/06/2012 $150.00 !Original Invoice Amount Assessed

1 _ _ . _ :-:::;---,::-:--_:--:--:-_~----_t_-------__+_-------_+---.----$-15-0-.0-0 1 I ICiVil Penalty Amended Amount I

iCiv{ penalty Amended Amount - - - ~ ,- ~ ~ - I I

~~i-Vi~l ~p-e-na~l~ty-A7m-e-n~de-d~A-m-o-u-n~t------r--------r------- -1--------I , ,Sent to Central Operations Branch I I !Payment - ---- --- -- ----._- - - - -,

I __ 01/07/2013

_I $150.00 I $0.00

Ipayment -- - -- -- ----- - -- -- - -

I :payment , I I I I Payment I I I

I Payment

.. _- - - -- - ------ ,- -r---I

_ ..

I

iCOMMENTS: --,

!Paid in full on 01/07/2012 with check #4035 dated 01/03/2012, remitter Mission Home_

lie 422A (10/1 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY.--.", CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

NOTICE OF CIVIL PENALTIES Due

III Initial Invoice o Final Notice Date Sent ___ ____ _

INVOICE NO. ~08:c..:.0...:...:13_28 __ _ REGIONAL OR COUNTY OFFICE NUMBER_08 ___ _

FACILITY NAME


2849 MELBOURNE DRIVE CITY I STATE


2849 MELBOURNE DRIVE CITY [ STATE SAN DIEGO CA


CURMAK, GUNNUR ADDRESS

2996 MISSION VILLAGE DR CITY I STATE

SAN DIEGO CA

I ZIP CODE

92123

I ZIP CODE

92123

J ZIP CODE

92123

'FiSCAL'YEAR

2012/13

FACILITY TYPE

RCFE

I FACILITY NUMBER

374603043

I SUPERVISOR APPROVAL

TITLE

DATE LlC 422 SENT


84037


See attached LlC 421 series form. As a result, you were assessed the following amount:

(DATE)

Penalty Amount OriQinally Assessed: 12106/2012 $ 150.00 (DATE)

Penalty Amount Amended : $ (DATE)

Payment Received: $


Send a copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number(s) on your check.




SAN DIEGO CA 92108

FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OFTHE FOLLOWING:



• COURT ACTION

LlC 422 (9/11) (PUBLIC)

STATE 0: CALI FOR.N IA • HEALTH AND HUMAN SERVICES AG/~Y CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CIVIL PENALTY ASSESSMi:NT --IMMEDIATE $150

FACILITY NAME DATE

Mission Home 4 12106/2012 FACILITY ADDRESS CITY STATE ZIP CODE

2849 Melbourne Drive San Diego CA 92123

FACILITY #: LlCENSEE(S)

Gunnur Curmak 374603043

A Licensing Report (LiC 809 or LlC 9099) was issued on --'-1_1/_1_5/_2_01_2 _____ giving notice that your facility has been found in DATE

violation of one or more requirements for which an immediate civil penalty is warranted in accordance with One or more of the following California Health and Safety Code Sections: 1548, 1568.0822, 1569.49, 1596.99 and 1597.58.

You are hereby notified that an immediate civil penalty of $150 per violation followed by $150 per day per violation until corrected is assessed for the period of 11/15/2012 through 11/15/2012 for the following violations:

DATE DATE

[lJ Violations which result in injury, sickness or death of a client in care. (Does not apply to Residential Care Facilities for the Chronically III or Foster Family Homes.)

o Fire clearance violations (Does not apply to Family Child Care Homes.)

o Absence of supervision

o Accessible bodies of water

o Accessible firearms, ammunition, or both

o Licensing agent refused entry to a facility or any part of a facility

o The presence of an excluded person on the premises

Total # of (Per Day) Violations:

Total Penalty Assessed



NAME OF LICENSING PROGRAM ANALYST LICENSING PROGRAM ANALYST

Lisa Quinlivan

NAME OF FACILITY REPRESENTATIVEfTITLE FACILITY REPRESENTAnVE

1- n'?-pVL. ~n+e.~ SUPERVISOR REVIEW/SIGNATURE (FOR INTERNAL USE ONLy)

L1C 421C (7/ 11)

DATE

X $150 $ 150.00

12106/2012

DATE

12106/2012

DATE

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICE COMMUNITY CARE LICENSING DIVISION

CASH STATE RECEIPT FOR FEE TYPE PAID: CIVIL PENALTY

THESE FEES ARE NON-REFUNDABLE

FACILITY NUMBER REMITIER PCA PAY TYPE DATE OF CHECK CHECK NUMBER TOTAL AMOUNT COLLECTED

374603043 Mission Home 84037 Check 01/03/2013 4035 $150.00

RECEIPT NO: DATE ISSUED: OFFICE:

R08-000247303 01/07/2013

08

STATE OF CALIFORNIA - HEAlTH AND HUMAN SERVICES AGENCY


FACILITY NAME: MISSION HOME 4 ADMINISTRATOR:CURMAK, JOHN ADDRESS: 2849 MELBOURNE DRIVE CITY: SAN DIEGO CAPACITY: 6

STATE:CA CENSUS:


CCLD R&tJional Office, 757~ METROPOLITAN DR. ~109 SAN DIEGO, CA 92108

FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE:

TYPE OF VISIT: Case Management UNANNOUNCEO TIME BEGAN:

374603043 740

(858) 569-0951 92123

12106/2012 01:00 PM 01:45 PM MET WITH: Gunnur Curmak, Licensee TIME COMPLETED:

NARRATIVE 1 licensing Program Analyst Lisa Quinlivan conducted a Case Management visit. The LPA was met by 2 Yolanda Penunuri , Caregiver. The Caregiver Yolanda called Licensee Gunnur Cunnak and she arrived during 3 the visit. The purpose of the visit is to issue two (2) Civil Penalties regarding a Substantiated Complaint where 4 the LPA conducted a visit on November 15, 2012. On the Complaint where two (2) allegations that on two (2) 5 different dates two (2) different Residents fell at the facility due to slick MOOring at the facility. These are 6 violations which resulted in injury of a Resident in care. 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

An exit interview was conducted with Gunnur Curmak, Licensee and a copy of this report and two (2) LlC 421 C Civil Penalties and Appeal Rights where left at the faCility.

SUPERVISOR'S NAME: Edna Musoke

LlCENStNG EVALUATOR NAME: Lisa Quinlivan


TELEPHONE: (619) 767-2333

TELEPHONE: (619) 767-2308

DATE: 12/06/2012

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


I DATE: 12/06/2012


lIC809 (FAS) - (06104) Page: 1 of 1



11/26/2012



Dear Licensee,



Section Cited: 87307(d)(3)(A) Date Due: 11/16/2012 Plan of Correction: The licensee shall secure residents rooms flooring so there are no fall hazards. Proof of correcUon shall be submitted to eel by 11/16/2012.

Section Cited: 87307(d)(3)(A) Plan of Correction: The licensee shall secure residents rooms flooring so there are no fall hazards. Proof of correcUon shall be submitted to eel by 11/16/2012.

Section Cited: 87211 (a)(1 )(8) Plan of Correction: The licensee shall read secUon 87211 and submit a written letter of understanding. The licensee shall submit a report for incident on 11/6/12 to eel by 11/16/12.

Section Cited: 87211 (a)(1 )(8) Plan of Correction: The licensee shall read secUon 87211 and submit a written letter of understanding. The licensee shall submit a report for incident on 11/8/12 to eel by 11/16/12.

LICENSING EVALUATOR NAME: Lisa Quinlivan


Corrections: Clearance Date: area rug with no skid back placed in all 11/16/2012 resident rooms. photos submitted .

Date Due: 11/16/2012 Corrections: Clearance Date: area rug with no skid back placed in all 11/16/2012 resident rooms. photos submitted.

Date Due: 11/16/2012 Corrections: Licensee submitted written statement and incident report

Date Due: 11/16/2012 Corrections: Licensee submitted written statement and incident report.



TELEPHONE: (619) 767-2308

DATE: 11/26/2012


~3'f9 ~~ 2)V' .

S~'jJ~o / M ~ 7

I

LPA: Lisa Quinlivan;

I have re-familiarized myself with Title 22 Section Code 87211. I understand the reporting requirements. I have read numbers 1-a,b,c,d 2-3b,1 ,2,3 and acknowledge your requirements for the future.

GIi/7/lifr- C~Jrm(/J{ 11/16//2-

/} /) 2#y1 a J:-~;r7fr?a ~

RECEIVED NOV 1 6 2012

COMMUNITV CAne UCeNS1NG SAN DIEGO RESIDENTIAL OFFICE

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES …cdn.sandiegouniontrib.com/news/documents/2013/09/16/MH4.pdf · state of caufornia· health and human services agency california department

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