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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600093
Report Date: 11/01/2023
Date Signed: 11/01/2023 02:07:32 PM

Document Has Been Signed on 11/01/2023 02:07 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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: 3DATE:
11/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:ADMINISTRATOR, BORKA SAPUNGINTIME COMPLETED:
02:18 PM
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On November 01, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to conduct the required annual inspection and met with the Administrator, Borka Sapungin. The LPA introduced herself, and stated the purpose of the visit.

LPA Mixson toured the facility along with the Administrator, and inspected the facility inside and outside. There were no obstructions to the indoor or outdoor passageways of the facility at the time of this visit.
The facility is a two story home, located at 820 Jacaranda Place, Escondido, CA. 92026. Physical Plant: The facility land line number is (760)747-2240 and is operable. The LPA observed the three resident bedrooms, and they are equipped with required furniture as per Title 22. The LPA inspected the facility bathrooms, and the hot water temperature tested within regulations. The two bathrooms were clean and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguisher. The LPA observed required postings such as, "If you See Something, Say Something" and the "Personal Rights" postings were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the residents. There was a designated storage space for the resident and staff files. Medications: The medications were locked, stored, and inaccessible to residents. The overall facility is clean, the furniture is in good condition. The facility air conditioning and other appliances were operable currently at the time of this visit. Food Service: There are the required food items as per the regulations and there is a variety of food items sufficient for the number of residents. Dishes and utensils were in sufficient supply and stored properly. Care & Supervision: Currently all three residents are in the community with one staff and there is one staff at the facility. Records Review: The LPA reviewed three resident files, three staff files. There were no Title 22, Division 6 Regulation violations observed and/or cited during todays visit. An exit interview was conducted and a copy of this report was given to the Administrator, Borka Sapungin.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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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