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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881470
Report Date: 04/22/2024
Date Signed: 04/22/2024 12:33:33 PM

Document Has Been Signed on 04/22/2024 12:33 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SOUTH UPAS ARFFACILITY NUMBER:
371881470
ADMINISTRATOR/
DIRECTOR:		TAHERI, SOGANDFACILITY TYPE:
735
ADDRESS:820 S UPAS STTELEPHONE:
(858) 722-5746
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 3CENSUS: 0DATE:
04/22/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Administrator, Sogand TaheriTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA met with Licensee, Soheila Rezazadeh and Administrator, Sogand Taheri. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 05/05/2023 for a total capacity of three (3) residents. Fire clearance was granted on 10/10/2023. LPA Kathleen Banrasavong observed the following:
Structure:
Facility is a one-story house with a second bedroom upstairs. There are two (2) resident’s bedrooms, one (1) office and one (1) staff bedroom, one (1) residents’ bathroom, one (1) staff bathroom, living room, dining area and kitchen. There was an attached two (2) car garage. There is not a pool.
Heating/Cooling System:
Central heating and air conditioning system are installed and operable. Temperature was set at 77 degrees.
Bedrooms:
Each resident bedroom #1, #2, #3, #4 were in good repair. Four (4) bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm and carbon monoxide alarms.
Bathrooms:
Two (2) resident’s bathrooms have a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and hand soap dispensers. LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 105 degrees Fahrenheit.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SOUTH UPAS ARF
FACILITY NUMBER: 371881470
VISIT DATE: 04/22/2024
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Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp drawer will be secured in a locked drawer located in the cabinet in the hallway. There was adequate room for food storage. LPA observed the stove and microwave to be operational. Refrigerator/freezer were in working condition.
Pantry had sufficient storage for non-perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in the hallway. Laundry detergents and cleaning supplies were observed in a closet away from residents.
Living/Family room:
There was a living room with furniture for all clients.
Linens and Hygiene Supplies:
An adequate supply of linens and hygiene supplies was stored in a cabinet in the hallway of the residence.
Yards/Outside:
Patio table and chairs were observed in the backyard. There was a gate on the northwest side and a self-latching closure.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted at the exits in the house. Ombudsman poster, Let-Us-No poster, Rights of Resident Council, Theft & Loss, Personal rights, Non-discrimination observed.
General items:
One (1) fire extinguisher was charged and located in the hallway with signage; fire extinguisher was charged 06/24/2023. Four (4) 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. Two (2) First Aid kits with required components were observed. There was a locked area for medication storage. Emergency food and water supply was observed. Pre-Licensing is complete, and this facility has six (6) deficiencies that need to be corrected and sent to the LPA by May 1st, 2024. An exit interview was conducted, the LIC 9102s and a copy of this report was given Administrator, Sogand Taheri.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC809 (FAS) - (06/04)
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