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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372008410
Report Date: 10/25/2023
Date Signed: 10/25/2023 05:37:59 PM

Document Has Been Signed on 10/25/2023 05:37 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:TODOS SANTOS ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
372008410
ADMINISTRATOR:JOHN DURKEEFACILITY TYPE:
735
ADDRESS:959 TOMORRO LANETELEPHONE:
(760) 723-6273
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 6CENSUS: 6DATE:
10/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:David Velenzuela, House ManagerTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility to conduct a required annual licensing inspection. LPA was met by David Valenzuela, House Manager and was granted entry into the facility. LPA spoke with Licensee, Susan Beals, and discussed the purpose of the visit.

A tour of the facility was conducted inside and out. LPA, accompanied by Mr. Valenzuela, conducted a general overall inspection, which included but was not limited to the following: Facility physical plant, food service, medication management, record review and facility administration. The facility is licensed to serve six (6) Adults with Developmental Disabilities, all of whom must be ambulatory.

The facility is a four (4) bedroom two (2) bathroom one story house. Three bedrooms are two clients to a room and one bedroom is reserved for live-in staff.

During today's inspection, LPA observed the following: Indoor and outdoor passageways were observed to be free from obstruction. There are no pools or bodies of water. Per Mr. Valenzuela, there are no firearms or other dangerous weapons in the facility. Poisons and cleaning agents were observed to be secured and inaccessible to residents in care. Facility fire clearance is maintained in conformity with State Fire Marshal regulations. LPA toured every room in the facility. Rooms designated as resident rooms had the required furnishings and sufficient lighting available. Licensee provided each resident with clean linen, in good repair, and sufficient hygiene products for personal use. The hot water temperature measured at 105.9 degrees F. The facility had a functioning carbon monoxide detector, multiple smoke detectors, and one operable fire extinguisher. The facility was stocked with a two-day supply of perishable food items and a seven-day supply of nonperishable food items. Staff records were reviewed and contained CPR/First Aid training, Health Screening Reports, and annual training. Resident records were reviewed and had a current Physician's Report, IPP, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication and Destruction Records. Medications were stored in a locked cabinet and were labeled and maintained in compliance with label instructions. Drills are conducted regularly, last drill was 8/31/23.

No deficiencies were observed during today's visit. This report was discussed with
Mr. Valenzuela and a copy of this report was provided to him at the conclusion of the visit.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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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