374600663-5-8-2023-18-AS-JARA-CRMQMY-20230508121819

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600663
Report Date: 05/08/2023
Date Signed: 05/08/2023 12:19:05 PM

Document Has Been Signed on 05/08/2023 12:19 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:	DOWNSTOWN VII		FACILITY NUMBER:	374600663
ADMINISTRATOR:	ELISSA CIAVERELLI		FACILITY TYPE:	735
ADDRESS:	2808 FOOTHILL DRIVE		TELEPHONE:	(760) 598-1668
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY: 4		CENSUS: 4	DATE:	05/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Assitant Executive Director, Susan Laubach		TIME COMPLETED:	12:30 PM

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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 5/8/2023 at 10:20 a.m. LPA was granted entry and met with , Susan Laubach Assistant Executive Director, who was informed of the purpose of the visit. At the time of the visit there was (4) staff and (0) client present.

The facility is a one story home with (4) bedrooms and (3) bathrooms and pool. No firearms are being kept at the facility. The clients served are adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that staff have received infection control training.

Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. Pool is surrounded by a locked gate. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature was recorded at 105.4F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DOWNSTOWN VII	FACILITY NUMBER: 374600663
	VISIT DATE: 05/08/2023

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Record Review and Resident/Staff Files: LPA reviewed (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. The listed administrator has a current administrator's certificate. Two (2) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in closet. LPA reviewed client medications for (2) client and found all medication listed on MARS and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. Staff agreed to send the LPA the updated LIC610D by the end of the business day. The staff agreed to send LPA proof of the last fire drill by the end of the business day. LPA observed all facility exits were clear from obstructions.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to the Assistant executive director, Susan Laubach.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC809 (FAS) - (06/04)

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