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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600093
Report Date: 11/23/2021
Date Signed: 11/29/2021 08:57:12 AM

Document Has Been Signed on 11/29/2021 08:57 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:JACARANDA'S HOME CAREFACILITY NUMBER:
374600093
ADMINISTRATOR:SAPUNGIN, BORKAFACILITY TYPE:
735
ADDRESS:820 JACARANDA PLACETELEPHONE:
(760) 747-2240
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 4DATE:
11/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Lincesee Borka SapunginTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required 1 - Year Visit. LPA was greeted by Licensee Borka Sapungin, identified himself, and discussed the purpose of the visit.

LPA Martinez conducted a tour of the facility with Licensee Borka Sapungin. In accordance with the Department’s Infection Control program, LPA Martinez provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808).

LPA Martinez observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors, and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit.

An exit interview was conducted with Licensee Borka Sapungin, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail. A read receipt email confirms these documents were received.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2021
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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