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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881529
Report Date: 01/04/2024
Date Signed: 01/04/2024 10:55:51 AM

Document Has Been Signed on 01/04/2024 10:55 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A&R RESIDENTIAL CARE IIIFACILITY NUMBER:
371881529
ADMINISTRATOR:JAZMIN, ROBERTFACILITY TYPE:
735
ADDRESS:722 SHERIDAN AVENUETELEPHONE:
(858) 204-5715
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 4CENSUS: 0DATE:
01/04/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Robert Jazmin TIME COMPLETED:
11:00 AM
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On Thursday, 1/4/2024, Licensing Program Analyst (LPA) Janette Romero conducted an announced visit to conduct a pre-licensing inspection. LPA met with Applicant, Robert Jazmin.

Fire clearance has been granted for (4) ambulatory clients ages 18 through 59. Applicant Jazmin's administrator certificate expires on 5/28/2024.

LPA conducted of a tour of the facility’s interior and exterior. The facility is made up of four (4) client bedrooms and two (2) client bathrooms along with a kitchen, living/family room, and garage. LPA did not observe bodies of water on the premises. The physical plant is in good repair. Indoor and outdoor passageways are free of obstructions. The facility has an outside shaded seating area available for future clients. LPA observed a charged fire extinguisher, operating smoke alarms, carbon monoxide detectors, and a working land line. LPA observed locked storage areas for cleaning solutions, centrally stored medications, and knives/sharp instruments. Client and staff files are secured in a file cabinet stored near the kitchen.

LPA toured the bedrooms. Client bedrooms had the required bedding, furniture, and functional lighting. LPA observed storage area for additional linen and towels available in the hallway cabinet. LPA toured the kitchen and non-perishable food was stored in a safe and healthful manner. The facility had a 7-day supply of nonperishable food items. LPA observed plenty of storage room in the refrigerator for perishable foods.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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: A&R RESIDENTIAL CARE III
FACILITY NUMBER: 371881529
VISIT DATE: 01/04/2024
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LPA toured the client bathrooms. Client bathrooms are equipped with non-skid mats in the shower. The hot water temperature in client bathrooms measured at 110-degrees Fahrenheit.

Emergency disaster plans, personal rights, and complaint procedures were posted in living/family room wall. LPA observed one complete first aid kit. Living/family room has a working television and adequate seating in common areas.

During today's visit, LPA did not observe any issues or concerns. Final approval of licensure will be granted by the Centralized Application Bureau analyst.



An exit interview was conducted where a copy of this report was discussed and provided to Administrator Jazmin.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC809 (FAS) - (06/04)
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