370808412-6-1-2023-08-AS-RGAZ-CSDRWZ-20230601132358

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370808412
Report Date: 06/01/2023
Date Signed: 06/01/2023 01:24:18 PM

Document Has Been Signed on 06/01/2023 01:24 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	CLARK ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	370808412
ADMINISTRATOR:	ADRIANNE CLARK		FACILITY TYPE:	735
ADDRESS:	2402 EUCLID AVENUE		TELEPHONE:	(619) 579-0783
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92019
CAPACITY: 4		CENSUS: 3	DATE:	06/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Licensee Adrianne Clark		TIME COMPLETED:	01:30 PM

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Licensing Program Analyst (LPA) Riza Alvarez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Licensee/Administrator Adrianne Clark.

According to the facility’s license, the facility has a maximum capacity of four (4) ambulatory clients. During today’s inspection, all three (3) clients are in the facility.

LPA, accompanied by Licensee, 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. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 111.7 F, bathroom #1 sink was 111 F, and bathroom #2 sink was 111.5 F. Room temperature was 71 F.

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: John Rante
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CLARK ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 370808412
	VISIT DATE: 06/01/2023

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[CONTINUED FROM LIC809]

Pool was present on the nort east side of the premises, it was fenced and locked. Per Licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers (2) were serviced within the last 12 months. First aid kits (2) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed the Licensee and all clients. LPA reviewed all client and staff 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.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Licensee Adrianne Clark to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

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