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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600093
Report Date: 03/10/2022
Date Signed: 03/11/2022 09:59:03 AM

Document Has Been Signed on 03/11/2022 09:59 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,
, CA
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:
03/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Licensee, Borka SapunginTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA), Sabel Martinez conducted an unannounced case management visit to the facility in response to a self reported incident. LPA was greeted by Licensee, Borka Sapungin, introduced himself, and discussed the purpose of the visit

On 3/9/2022, the Regional Office received an Unusual Incident Report (LIC 624) of a resident who left the facility, and had not returned to the facility. During today's visit, the LPA conducted a tour of the facility, conducted an interview with the Licensee, and reviewed resident records. No deficiencies were cited during today's visit, and future visits may be necessary.

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. An email read receipt confirms these documents were received by Licensee, Borka Sapungin.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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