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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600093
Report Date: 11/14/2024
Date Signed: 11/14/2024 12:53:57 PM

Document Has Been Signed on 11/14/2024 12:53 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JACARANDA'S HOME CAREFACILITY NUMBER:
374600093
ADMINISTRATOR/
DIRECTOR:		SAPUNGIN, BORKAFACILITY TYPE:
735
ADDRESS:820 JACARANDA PLACETELEPHONE:
(760) 747-2240
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 2DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Licensee, Borka SapunginTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 11/14/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to conduct a required annual inspection. LPA was greeted and granted entry by Licensee, Borka Sapungin who was informed of the purpose of the visit. The facility has a fire clearance for six (6) ambulatory clients and serves adults ages 18 through 59. During the visit there was two (2) clients and Licensee present.

LPA toured the facility with Licensee Sapungin and observed the facility is made up of a two-story home with three (3) client bedrooms, two (2) bathrooms, a kitchen, dining room, and attached garage. Client bedrooms had the required bedding, furniture and lighting. Bathrooms had working toilets and wash basins. Indoor and outdoor passageways were free of obstruction. There are no bodies of water on the premises. The facility had more two-day supply of perishable foods and seven-day supply of non-perishable foods, which were stored in a safe and healthful manner. Medications are secured in a locked kitchen cabinet. LPA toured the garage and observed a laundry washer and dryer along with additional food and water. Licensee Sapungin tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed a charged fire extinguisher mounted in one of the hallways. The facility's last fire and earthquake drill was conducted on 9/20/2024. The facility does not safeguard the clients' cash resources. Licensee and both individuals associated with the facility have a valid first aid/cardiopulmonary certification. LPA reviewed both client files, which had Departmental required records.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Licensee Sapungin.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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