371881399-5-23-2023-18-AS-YDEO-CS4JKT-20230523070737

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 371881399
Report Date: 04/17/2023
Date Signed: 05/23/2023 07:08:09 AM

Document Has Been Signed on 05/23/2023 07:08 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:	HOPE ARF		FACILITY NUMBER:	371881399
ADMINISTRATOR:	DOST, LEENA		FACILITY TYPE:	735
ADDRESS:	551 VIA DEL CABALLO		TELEPHONE:	(760) 877-5773
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92078
CAPACITY: 4		CENSUS: 0	DATE:	04/17/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Leena Dost, Licensee		TIME COMPLETED:	12:30 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) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 10:30 AM, LPA met with Licensee/Administrator Leena Dost. An initial application for Profit Corp to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 11/15/2022 for a total capacity of four (4) ambulatory residents. Fire clearance was granted on 1/23/2023. Infection Control Plan on file. LPA Delgado observed the following: Structure: Facility was a two-story house with three (3) resident bedrooms and two (2) resident bathrooms upstairs, living room, dining area, kitchen and office on the first floor. There was an attached two car garage in the front of the house and a one car garage attached on the side of the house. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway on the second floor to control entire house. Bedrooms: Each resident bedroom #1, #2, #3 (shared) will accommodate any ambulatory resident, three (3) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Bathrooms: The two (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap, 1/2 bathroom on the first floor. At 11:00 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 106.3 degrees Fahrenheit. (CONTINUED ON LIC 809C)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HOPE ARF	FACILITY NUMBER: 371881399
	VISIT DATE: 04/17/2023

NARRATIVE

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(CONTINUED FROM LIC 809)
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked cabinet located under the kitchen sink. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located upstairs. Laundry detergents and cleaning supplies were observed in in locked cabinet away from residents.
Living/Family room:
There was a living room for all clients and TV. Camera not plugged in was observed secured on the wall. Another camera was observed on the second floor not plugged in hanged on the wall in the Foyer Area for staff.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the second floor hallway of the residence and hygiene supplies secured under the bathroom sinks.
Yards/Outside:
Patio table and chairs were observed in the backyard. There was a gate on the North East side of the property with a self-latching hook. All outdoor pathways were free of obstructions. There is no bodies of water or pool.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the main hallway. Let-Us-No poster, Emergency numbers, Personal Rights, Theft and Loss, Administrator certificate, and CA Labor law observed.
General items:
Two (2) fire extinguishers were charged; missing inspection tags and located in the kitchen and upstairs . Six (6) smoke alarms and two (2) carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the Kitchen. First Aid kit missing required component, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Insufficient Emergency water supply was observed however the required 72-hour emergency food supply was not discernible from the regular food supply. Component III was waived, Licensee has other facilities and completed Comp III on 7/31/2019.
(CONTINUED ON LIC 809C)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HOPE ARF	FACILITY NUMBER: 371881399
	VISIT DATE: 04/17/2023

NARRATIVE

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(CONTINUED FROM 809C)

Pre-Licensing is incomplete and the following corrections to be resolved by 4/24/2023:

obtain a separate 72-hour emergency food supply
obtain additional emergency water
obtain and post visiting policy
obtain PPE supplies
obtain tweezers for First Aid kit
obtain Fire Extinguisher tags
obtain audio signal for back door for resident room #1
obtain a sample menu
obtain a night light for hallway that leads to bathrooms
obtain dressers for bedroom #2, #3
replace dead-bolt on back door room #1
replace locks/chain for fireplaces

An exit interview was conducted, and a copy of this report will be emailed and request receipt will requested.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

LIC809 (FAS) - (06/04)

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