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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604819
Report Date: 09/03/2026
Date Signed: 09/03/2026 04:55:58 PM

Document Has Been Signed on 09/03/2026 04:55 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:NEW WORLD VILLA NORTHFACILITY NUMBER:
374604819
ADMINISTRATOR/
DIRECTOR:		CHEN, ZAYDENFACILITY TYPE:
740
ADDRESS:15042 AMSO STTELEPHONE:
(858) 733-4907
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 5DATE:
09/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:02 PM
MET WITH:Caregiver Mariaelena BautistaTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Angelica Boyles and Patrice Bazemore conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Mariaelena Bautista.

LPAs, accompanied by caregiver, toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. LPAs observed Resident #1 (R1) laying in bed with two chairs placed in front of her bed. Staff reported the chairs are placed there to prevent her from getting up and falling.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. LPAs observed sharp objects and toxic chemicals/poisons accessible to residents, as they were not locked in the drawers and cabinets they were being stored in.



LPAs observed medications labeled, as required, and stored in locked areas, however, they were pre-poured into cups. Additionally, LPAs observed medication being centrally stored that were passed their discard date. Additionally, LPAs observed clean and used syringes being stored in re-purposed food containers.

(CONTINUED ON LIC 809C)
Simon Jacob
Angelica Boyles
DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2026
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: NEW WORLD VILLA NORTH
FACILITY NUMBER: 374604819
VISIT DATE: 09/03/2026
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(CONTINUED FROM LIC 809)

No pools or bodies of water were observed on the premises. Per caregiver, no firearms or ammunition are kept at the facility. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPAs observed resident records not locked in the cabinet they were being stored in and accessible.

Due to time constraints LPAs were unable to complete the visit and will return at a later date to conduct the remaining portion of this inspection.



Six deficiencies were observed and cited during today's visit per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). A plan of correction was jointly developed with caregiver.

An exit interview was conducted with Caregiver Mariaelena Bautista, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Angelica Boyles
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 09/03/2026 04:55 PM - It Cannot Be Edited


Created By: Angelica Boyles On 09/03/2026 at 03:53 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NEW WORLD VILLA NORTH
FACILITY NUMBER: 374604819

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2026
Section Cited
CCR
87309(a)

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Storage Space and Access
(a)...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives...sharp objects, and other similar items which could pose a danger to residents are in locked storage...
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Staff immedietaly removed knives, scissors, and chemicals from the drawers and cabinets that could not be locked and put them in the garage inacessible to residents in care. Staff will place a lock on the sharp drawer and chemical cabinet by POC due date.
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This requirement was not met as evidenced by:
LPAs obserevd the knife drawer in the kitchen to be unlocked and cleaning chemicals under the sink to be unlocked. This poses an immediate health and safety risk to 5 of 5 residents in care.
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Type A
09/03/2026
Section Cited
HSC1180.4(k)

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...Guidelines for Behavioral, Mechanical, and Physical Restraints...(k) A person in a facility … has the right to be free from the use of seclusion and behavioral restraints of any form imposed as a means of…convenience, or retaliation by staff. This right includes…to restrict the person’s freedom of movement…
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Staff immediately removed the chairs from R1's bed. Staff will do a training on personal rights by POC due date.
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This requirement was not met as evidenced by:
LPAs observed R1 laying in her bed with 2 chairs preventing her from getting up. Staff reported it is to prevent her from falling. This poses an immediate personal rights risk to 1 of 5 residents 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:
Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2026 04:55 PM - It Cannot Be Edited


Created By: Angelica Boyles On 09/03/2026 at 04:19 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NEW WORLD VILLA NORTH
FACILITY NUMBER: 374604819

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2026
Section Cited
CCR
87465(h)(5)

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Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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Staff reported they would immeditely cease pre-pouring medications and keep medications in their original packaging. Staff will complete a medication training by POC due date.
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This requirement was not met as evidenced by:
LPAs observed medications pre-poured in cups locked in the medication cabinet. This poses a potential health and safety risk to 5 of 5 residents in care.
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Type B
09/14/2026
Section Cited
CCR87465(i)

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Incidental Medical and Dental Care
(i) Prescription medications which…are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years...
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Staff reported they will discard R1's medications using the destruction log by POC due date.
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This requirement was not met as evidenced by:
LPAs observed 3 medications for R2 which were pass their discard date. This poses a potential health and safety risk for 1 of 5 residents 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:
Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2026 04:55 PM - It Cannot Be Edited


Created By: Angelica Boyles On 09/03/2026 at 04:26 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NEW WORLD VILLA NORTH
FACILITY NUMBER: 374604819

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2026
Section Cited
CCR
87629(b)(2)

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Injections(b)...the licensees who...retain residents who require injections shall be responsible for the following:(2) Ensuring that ...syringes, needles and other supplies...are stored as specified in Section 87465(c).
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Staff will obtain proper sharps collector containers for used syringes by POC due date.
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This requirement is not met as evidenced by:
LPAs observed used syringes not being stored in repurposed food containers. This poses a potential health and safety risk to 5 of 5 resdients in care.
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Type B
09/14/2026
Section Cited
CCR87506(c)(1)

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Resident Records (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents...
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Staff reported they will get a lock for the records cabinet by POC due date.
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This requirement is not met as evidenced by:
LPAs observed resident records being stored in an unlocked cabinet. This poses a potential personal rights risk to 5 of 5 residents 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:
Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
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