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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881379
Report Date: 12/21/2022
Date Signed: 12/21/2022 11:56:29 AM

Document Has Been Signed on 12/21/2022 11:56 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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:
12/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:ADMINISTRATOR, ROBERT JAZMINTIME COMPLETED:
12:10 PM
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On December 21, 2022, Licensing Program Analyst (LPA), Venus Mixson conducted a scheduled visit to complete a Pre-licensing inspection. LPA Mixson met with Administrator Robert Jazmin, and toured the facility inside and outside. The facility is a single story home with four bedrooms, two baths, kitchen, dinning room, living room, and two car garage. LPA Mixson observed sufficient food supply, and the overall facility to be in clean condition with a comfortable temperature. LPA Mixson observed passageways to be free from obstruction. Water temperature was tested and found to be within regulations. LPA Mixson observed where medications will be kept locked and inaccessible to clients. LPA observed smoke alarms/ carbon monoxide detectors are hardwire and operable. On 10//27/2022, the Escondido Fire Department cleared home for four ambulatory, 0 non ambulatory, and 0 bedridden residents. LPA Mixson observed food storage and preparation areas. Food preparation areas are clean and sanitary. Refrigerator and freezer are maintained at appropriate temperatures. The kitchen was observed to have dishes, silverware and pots and pans. All appliances are clean and operating properly. There is a sufficient supply of linens, towels and personal hygiene items. The first aid kit was reviewed; all items are present. LPA observed a dining area with sufficient seating for four. Outdoor space is suitable for resident use and was observed to be fully fenced with an unlocked gate. The fire extinguisher is completely charged and maintained.
The Administrator dialed 858-204-5715 and number was in working order.
An exit interview was conducted and a copy of this report was reviewed and given to the Administrator. COMP III reviewed.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2022
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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