370808298-9-1-2023-08-AS-AROS-CV9M2M-20230901091344

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370808298
Report Date: 08/31/2023
Date Signed: 09/01/2023 09:13:55 AM

Document Has Been Signed on 09/01/2023 09:13 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:	JACKIE'S BOARD AND CARE		FACILITY NUMBER:	370808298
ADMINISTRATOR:	JACKIE CUNNINGHAM		FACILITY TYPE:	735
ADDRESS:	10863 EL NOPAL		TELEPHONE:	(619) 258-7390
CITY:	SANTEE	STATE: CA	ZIP CODE:	92071
CAPACITY: 6		CENSUS:	DATE:	08/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Jackie Cunniingham Administrator		TIME COMPLETED:	02:15 PM

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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Jackie Cunningham, to whom LPA discussed the purpose of the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) clients of which two (2) may be non-ambulatory. During today’s inspection, there was a total of six (6) clients in care, all of whom are ambulatory.

LPA, accompanied by the administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant. Hot water temperature at taps accessible to clients were all compliant.

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. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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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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: JACKIE'S BOARD AND CARE	FACILITY NUMBER: 370808298
	VISIT DATE: 08/31/2023

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[CONTINUED FROM LIC 809]

The spa is non-operable, and no water is in the spa. There is an above ground pool on the premises. Per Administrator and corroborated by LPA observation/verification, firearms are stored in locked areas and are kept separately from ammunition.

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and reviewed multiple staff and client records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. Administrator presented proof of current/active business liability insurance and surety bond.

No deficiency was issued however LPA issued Technical Assistance for pool fencing.

An exit interview was conducted with Jackie Cunningham, to whom copies of this report, the Technical Assistance and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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