371881394-3-1-2024-18-AS-JSRS-D2Y7BB-20240301203049

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 371881394
Report Date: 03/01/2024
Date Signed: 03/01/2024 08:31:01 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/01/2024 08:31 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	DOLORE HOME		FACILITY NUMBER:	371881394
ADMINISTRATOR:	ARACELI SONGCO		FACILITY TYPE:	740
ADDRESS:	1412 DOLORE PLACE		TELEPHONE:	(619) 717-1574
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92027
CAPACITY:	6	CENSUS: 3	DATE:	03/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Arceli Songca, Administrator		TIME COMPLETED:	01:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility to conduct an annual visit. LPA was granted access to the home by Victoria Baul, Caregiver. LPA informed Miss Baul the purpose of today’s visit was to inspect the facility to ensure the facility is in compliance with the rules and regulations of California Code of Regulations. LPA conducted a general overall inspection, which included, but was not limited to, the following: physical plant; interior and exterior and records review. Administrator, Araceli Songco arrived shortly after. The facility is licensed for up to (6) residents of which (5) may be Non-ambulatory residents, (1) bedridden and is approved for (6) Hospice waivers. Physical Plant: The one story home consists of (6) resident bedrooms, (2) restrooms, a living room, kitchen and dinning area, caregiver living quarters and backyard area. LPA observed the home was maintained at a comfortable temperature of 71 degrees F. Per Administrator, no ammunition is kept in the home. Resident bedrooms were clean and were observed to have the required furniture, bed linens, proper lighting, drawer/closet space to accommodate each resident. Resident restrooms were checked and observed to be clean; toilets and water faucets worked properly, shower was free of mold/mildew, and Non-skid mats were in place. Common areas were clean and all doorways were clear of obstructions inside the home. The kitchen was checked and observed to be within Title 22 regulations. There was an adequate supply of food for residents in care; a minimum of one week supply of non-perishable and a two day supply of perishable food.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DOLORE HOME	FACILITY NUMBER: 371881394
	VISIT DATE: 03/01/2024

NARRATIVE

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Smoke and carbon monoxide detectors were checked, and were in good working order. Fire extinguisher was fully charged. LPA observed all sharps to be locked an secure in a cabinet drawer.

LPA measured the water temperature in the restrooms and found the water, in the hall, to be within regulatory limits, measuring at approximately 110.3 degrees F. Resident bath towels and toiletries were adequately stocked. Common areas were clean and all doorways were clear of obstructions inside the home. The kitchen was checked and observed to be within Title 22 regulations. LPA toured the backyard; no pool or bodies of water were observed on the premises, the backyard was clean and clutter free.

Records Review: A disaster, mass casualty plan as well as the Community Care Licensing Complaint poster were observed to be posted at the facility. LPA reviewed staff/resident records and checked medications. LPA did not observe any excluded persons on premises and all staff on premises had proper finger print clearance. Resident records were current and had proper admission agreements. No prohibited health conditions were observed. All staff records were current and all training was up to date. Drills are conducted regularly.

Based on this inspection, there were no deficiencies observed at this time in the areas evaluated. An exit interview was conducted with the Administrator. A copy this report and the LIC811 was provided to the Administrator.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC809 (FAS) - (06/04)

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