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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602817
Report Date: 09/03/2025
Date Signed: 09/03/2025 11:03:26 AM

Document Has Been Signed on 09/03/2025 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:
09/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Ferdinand Jerez, Direct Care StaffTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 09/03/25 Licensing Program Analyst (LPA) Javina George made visit to conduct a 1 year required inspection. 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. Below are the observations made during today's inspection:

The are a total of (6) bedrooms of which 2 bedrooms are for live in caregivers. The governing body was observed to be in good standing, and the facility annual fees that were due on 09/30/25 have been paid. LPA verified facility contact information with no changes needed.

The facility was observed to be clean, with the passageways being free of any obstructions. The facility was observed to have an adequate linen, and personal hygiene supply for client use. The chemicals, sharps and other hazardous items were locked and inaccessible to clients in care. The medications were reviewed and are being given as prescribed, as evidenced by the medication Authorization record (MAR). The hot water was tested and was found to be within regulatory limits measuring at 105.8 degrees Fahrenheit.

The cover/lid at the top of the toilet was observed to have been replaced with a temporary wood lid/cover, due to client having a behavior resulting in a replacement being ordered, but it did not match, therefore it was returned and a new one is being sent. The facility was observed to have fire extinguishers fully charged, that were last serviced on 08/22/25. The smoke and carbon monoxide detectors were tested and observed to be operable. There are no known guns, ammunition, pools or bodies of water, on the premises. The last emergency disaster drill was conducted on 07/01/25, with the next one being due in October 2025.
NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EUREKA SPRINGS HOME
FACILITY NUMBER: 374602817
VISIT DATE: 09/03/2025
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Client Personal and Incidental (P&I) funds were reviewed with two discrepancies found, however the balance was corrected during LPAs visit. A file review of both staff and client records was conducted. The client files were observed to have medical assessments, IPP, and or updated ISP and appraisal.

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, as there was a 2 day of perishable and a 7 day supply of non perishable food items. An exit interview was conducted and a copy of this report was reviewed and provided to Ferdinand Jerez, Direct Care Staff.
NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC809 (FAS) - (06/04)
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