<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600947
Report Date: 05/05/2023
Date Signed: 05/05/2023 03:46:09 PM

Document Has Been Signed on 05/05/2023 03:46 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:JIMLYS ARFFACILITY NUMBER:
374600947
ADMINISTRATOR:SHERYL ANN BARAWIDFACILITY TYPE:
735
ADDRESS:1010 METCALF STREETTELEPHONE:
(760) 781-1197
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 6DATE:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Staff, Jeannie EspirituTIME COMPLETED:
03:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 5/5/2023 at 12:00 p.m. LPA was granted entry and met with Staff, Jeannie Espiritu, who was informed of the purpose of the visit. At the time of the visit there was (3) staff and (6) client present.

The facility is a one story home with (4) bedrooms and (2) bathrooms. No pools or 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 and client interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies. 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.



Physical Plant: LPA observed the client bedrooms. Physical plant was observed to be in disrepair,. LPA observed dilapidated slate on the house exterior, broke dishwasher, damaged client dresser, visibility dirty floors, door frames and walls in the facility. Deficiency was cited for this and plan of correction was created, The outdoor area was observed to be free of hazards. Laundry equipment was observed to be operational. The sharp and dangerous objects were observed to be locked and inaccessible to clients in medication cabinet. The smoke detector and carbon monoxide was operational, and the hot water temperature 108F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment. LPA observed the facility did not meet the required 2-day supply of perishable and 7-day supply of non-perishable foods. This deficiency was documented along with plan of correction.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
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: JIMLYS ARF
FACILITY NUMBER: 374600947
VISIT DATE: 05/05/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator does not posses a current administrator's certificate, and informed LPA that they are stilll working on their recertification classes. Expiration date for certificate was 8/1/2022. Deficiency was cited for this along with plan of correction.

Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in a cabinet. LPA reviewed client medications for (3) clients and found that medication had proper labeling, and was accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan was last updated in 2022, and did not possess the required of the updated LIC610D. Deficiency was cited for this and plan of correction was documented. LPA reviewed documentation showing the facility's last fire conducted in April of 2023, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit.

An exit interview was conducted where a copy of this report along with deficiency pages and appeal rights were provided to the Staff, Jeannie Espiritu.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/05/2023 03:46 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/05/2023 at 03:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: JIMLYS ARF
FACILITY NUMBER: 374600947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above with window sills, door frames, exterior wooden slats, broken dishwasher, visability dirty floors and walls. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
1
2
3
4
The staff agreed to send the LPA photos of these items cleaned and repaired by the POC due date. The staff also agreed to send the LPA a written cleaning plan on how they plan to clean the floors of the facility and maintain the facility in clean condition.
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above with listed adminsitrator not having an updated certification. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
1
2
3
4
The staff agreed to send the LPA a written plan on how the facility plans to meet this requirment moving forward by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/05/2023 03:46 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/05/2023 at 03:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: JIMLYS ARF
FACILITY NUMBER: 374600947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above with facility food supply that did nto meet the department requirments. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
1
2
3
4
The staff agreed to send the LPA a written plan on how the facility plans to stay in compliance with sfood supply for residents. This is due bny the POC due date.
Type B
Section Cited
CCR
80023(b)
Disaster & Mass Casualty Plan
(b) The plan shall be subject to review by the licensing agency and shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above with LIC610D that had not been updated since 2022 and had not been updated to the 9-page LIC610D to meet department requirements. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
1
2
3
4
The staff agreed to send the LPA the written plan by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6