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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881379
Report Date: 11/10/2022
Date Signed: 11/10/2022 01:46:20 PM

Document Has Been Signed on 11/10/2022 01:46 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:A&R RESIDENTIAL CARE IIFACILITY NUMBER:
371881379
ADMINISTRATOR:JAZMIN, ROBERTFACILITY TYPE:
735
ADDRESS:812 ALBERT COURTTELEPHONE:
(858) 204-5715
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 4CENSUS: 0DATE:
11/10/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Alexander Raymundo; Robert Jazmin(Applicant; Administrator)TIME COMPLETED:
01:23 PM
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Facility Type: ARF
Application Type: INITIAL
Capacity: 4
Census (if any clients in care): 0

COMP II Participants: Alexander Raymundo/ Robert Jazmin(Applicant/Administrator)
Interview Method: Telephone interview with CAB

Applicant/Administrator participated in COMP II. During COMP II, Applicant/
Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of
following areas:
1. Facility operation: License type, client/resident populations, and program
2. Applicant and Administrator qualifications
3. Staff Qualifications - hiring procedures, responsibilities; training
4. Program policies -restricted/prohibited health conditions, medication management;
incident reporting to CCLD; food service and management, Activities program
5. Grievances, Complaints, Community resources; Abuse reporting
6. Application document review and technical assistance- Criminal record clearance,
Health screening, Fire clearance, First Aid/CPR certificate, Administrator Certificate,
Financial verification, Pre-licensing inspection, Compliance history, Control of property
SUPERVISORS NAME: Tracy Thompson
LICENSING EVALUATOR NAME: Ricmar Soriano
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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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