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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602817
Report Date: 09/10/2024
Date Signed: 09/10/2024 11:03:43 AM

Document Has Been Signed on 09/10/2024 11:03 AM - 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:EUREKA SPRINGS HOMEFACILITY NUMBER:
374602817
ADMINISTRATOR/
DIRECTOR:		JIMENEZ, JEFFREYFACILITY TYPE:
735
ADDRESS:556 EUREKA DRIVETELEPHONE:
(760) 294-5602
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 5DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Ferdinand Jerez, Direct Care StaffTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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On 09/10/24 at 9:20am Licensing Program Analyst (LPA) Javina George made an unannounced. LPA was greeted and granted entry by Direct Care Staff Ferdinand Jerez, where LPA explained the purpose of the visit. At the time of the visit there was (1) staff and (0) clients present as they were all at the day program, therefore no interviews were conducted. Below are the observations made during today's inspection:

LPA conducted a tour of the interior and exterior areas of the facility. The facility was observed to be clean, clutter and odor free. The passageways were observed to be free and clear from obstruction. The medications were reviewed and are being given as prescribed. The hot water was tested and was found to be within regulatory limits measuring at 105 degrees Fahrenheit. The facility was observed to have fire extinguishers fully charged with the tag in tact. The smoke and carbon monoxide detectors were tested and observed to be operable. There are no guns, ammunition, pools or bodies of water, on the premises.

The emergency disaster drills are being conducted on a monthly basis, the last drill was conducted on 09/01/24. The clients Personal and Incidental (P&I) funds were reviewed and verified that the amount indicated on the log was present. A file review of both staff and client records was conducted. The client files were observed to have medical assessments, and IPP. All staff present were observed to have proper criminal record clearance and to be associated to the facility. In addition staff possess valid CPR certification and the Administrator Jeffrey Jimenez was observed to have a valid administrator's certificate which expires on 06/01/26. The facility was observed to have a sufficient food supply. Based on today's inspection no deficiencies were observed. The facility was observed to be in compliance with the California Code of Regulations (Title 22, Division 6, Chapter 6).

An exit interview was conducted and a copy of this report was reviewed and provided to Ferdinand Jerez, Direct Care Staff.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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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