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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601201
Report Date: 04/28/2023
Date Signed: 04/28/2023 06:18:17 PM

Document Has Been Signed on 04/28/2023 06:18 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 ARF 2FACILITY NUMBER:
374601201
ADMINISTRATOR:SHERYL BARAWIDFACILITY TYPE:
735
ADDRESS:1045 SENDERO AVENUETELEPHONE:
(760) 743-4387
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 5DATE:
04/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator, Philip AquinoTIME COMPLETED:
06:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 4/28/2023 at 03:00 p.m. LPA was granted entry and met with staff, Philip Aquino, who was informed of the purpose of the visit. The administrator, Sherly Barawid was contacted over the phone during the visit, and acting administrator Liz Barawid was present for a portion of the visit. At the time of the visit there was (3) staff and (5) clients present.

The facility is a one story home with (5) bedrooms and (4) bathrooms with attached garage. 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 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 all staff had infection control training.



Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be cluttered. (1) resident was storing personal items in a cardboard box. A deficiency was documented for not providing the resident adequate storage for their belongings. The outdoor area was observed to be free of hazards. 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 unlocked in the facility kitchen and client restroom, chemicals were observed unlocked in client restroom. LPA had staff secure these items immediately. LPA was informed and observed that all resident share 2-in-1 soap and tooth paste. LPA observed a tooth brush with brown grime next to another client toothbrush. Staff stated this was used to clean the restroom sink and toilets. Deficiency was cited for this, so clients can have their designated hygiene items.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: JIMLYS ARF 2
FACILITY NUMBER: 374601201
VISIT DATE: 04/28/2023
NARRATIVE
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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 administrator informed LPA that they do not have needs and services plan for these residents or any other resident in the home. Deficiency was documented for this.

Health Related Services/ Incidental Medical Services: All client medication was locked in a pantry in the kitchen. 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. LPA reviewed documentation showing the facility's last fire and earthquake drills, which did not meet the department requirements. Deficiency was cited for this. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the facility such as emergency food and flash lights.

Food Service: LPA observed facility kitchen had unlabeled and expired foods in facility fridge and on kitchen counters. Deficiency was documented for this. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

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.

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

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 04/28/2023 06:18 PM - It Cannot Be Edited


Created By: Janira Arreola On 04/28/2023 at 05:38 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 2
FACILITY NUMBER: 374601201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with poswered bleach, knifes, scirssors and other sharps such as a shaving razor that were left unlocked. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2023
Plan of Correction
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The licensee agreed to have the staff sign statement stating that they hae read and understood the regulation section above. Also state where the staff will store the sharp and dangerous objects. This is due by the POC due date.
Type A
Section Cited
CCR
85088(c)(3)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (3) Portable or permanent closets and drawer space in each bedroom to accommodate the client's clothing and personal belongings.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with resident that was storing their personal belongings in a cardboard box in his room. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2023
Plan of Correction
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The licensee agreed to send the LPA proof of correction of the items in the cardboard box in proper storage area for the resident 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: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/28/2023 06:18 PM - It Cannot Be Edited


Created By: Janira Arreola On 04/28/2023 at 05:39 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 2
FACILITY NUMBER: 374601201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85088(c)(5)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (5) Feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with hygiene items that were kept locked, and staff stating that all resident use the same 2-in-1 wash and same toothpaste tub. It was also found that a tooth brish with bron grime on the bristles was used for cleaning the toilet and sink of the restroom and was placed next to another residents toothbrush. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2023
Plan of Correction
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The licensee agreed to have staff sign a written statement that the resident will have their own hygiene items that are in sanatary condition. Th staff must also send proof of correction of the hygiene kits for the residents by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/28/2023 06:18 PM - It Cannot Be Edited


Created By: Janira Arreola On 04/28/2023 at 05:39 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 2
FACILITY NUMBER: 374601201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with the licensee stating that they do not have needs and services plans for the any residents. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2023
Plan of Correction
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The licensee agreed to send the LPA the needs and services plan for all residents by the POC due date.
Type B
Section Cited
CCR
80076(a)(18)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observationand interview, the licensee did not comply with the section cited above with the facility fridge having expired food and unlabeled food . Food was transferred into containers and staff was unable to state what was in these containers, such as a gray thick liquid. Rotten friuits and vegetables wer observed on kitchen counters and in fridge.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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The licensee agreed to send the LPA proof of the correction by the poc due date, to remove expired food and place labels on food.
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: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 04/28/2023 06:18 PM - It Cannot Be Edited


Created By: Janira Arreola On 04/28/2023 at 05:39 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 2
FACILITY NUMBER: 374601201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review)], the licensee did not comply with the section cited above with last fire drill on record showing to be in July of 2021. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Licensee agreed to conduct a fire drill and earthquake drill with all facility staff by the POC due date, and send proof to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023


LIC809 (FAS) - (06/04)
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