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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601222
Report Date: 01/16/2024
Date Signed: 01/16/2024 02:11:42 PM


Document Has Been Signed on 01/16/2024 02:11 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:FAMILY RESORT REST HOME INC.FACILITY NUMBER:
374601222
ADMINISTRATOR:NELLY M.CUSTODIAFACILITY TYPE:
740
ADDRESS:3014 EL KU AVENUETELEPHONE:
(760) 489-0415
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY:6CENSUS: 1DATE:
01/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:ADMINISTRATOR, NELLY CUSTODIATIME COMPLETED:
02:15 PM
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On January 16, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the required annual inspection and met with the Administrator, Nelly Custodia. The facility file review was conducted in the office and additional records were requested and reviewed on site. The facility is licensed for six elderly adults and operating at a capacity of one.

LPA Mixson toured the facility along with the Administrator and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single-story home, located at 3014 El Ku Avenue. Escondido, CA 92025. Physical Plant: The facility phone number is (760) 489-0415 and is operable. The LPA observed the resident's bedroom, and it was equipped with required furniture as per Title 22, at the time of this visit. The LPA inspected facility bathrooms, and the hot water temperature tested within regulations. The bathrooms were clean and appliances were operating appropriately currently 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" the "Personal Rights" and the Ombudsman postings were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the resident and staff files and it was locked. Medications: were reviewed, locked and inaccessible to residents, and there was a 30 day supply. The overall facility is clean, the furniture is in good condition. The facility heating system and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly. Care & Supervision Facility has sufficient staff, one staff at the time of this visit and the staff was engaging the resident in activity and snack. Records Review: The LPA reviewed staff and resident files and conducted staff interviews, and resident interviews. Previous Community Care Licensing forms were reviewed. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit. An exit interview was conducted and a copy of this report was given to the Administrator, Nelly Custodia.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
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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