374602932-4-10-2023-08-AS-ARAZ-CQRNYN-20230410105302

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602932
Report Date: 04/10/2023
Date Signed: 04/10/2023 12:37:13 PM

Document Has Been Signed on 04/10/2023 12:37 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ZAMBRANA'S ADULT RESIDENTIAL FACILITY #3		FACILITY NUMBER:	374602932
ADMINISTRATOR:	SYLVIA FREEMAN		FACILITY TYPE:	735
ADDRESS:	534 E STREET		TELEPHONE:	(619) 737-0076
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91910
CAPACITY: 4		CENSUS:	DATE:	04/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Licensee Sylivia Freeman		TIME COMPLETED:	11:15 AM

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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Licensee Sylvia Freeman.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, all of whom must be ambulatory. During today’s inspection, there were a total of four (4) clients in care, and per medical records, all were ambulatory. This facility does not feature a secured perimeter or delayed egress doors.

LPA toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, sinks and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 116 F, Bathroom #1 sink was 117 F, bathroom sink #2 was 117 and bathroom sink #3 was 116 F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 68 F.

Refrigerator and freezer temperatures were compliant; refrigerator temperature was 33 F and freezer was 0 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ZAMBRANA'S ADULT RESIDENTIAL FACILITY #3	FACILITY NUMBER: 374602932
	VISIT DATE: 04/10/2023

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[CONTINUED FROM LIC 809]

There was no pool or large bodies of water on the premises. According to the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and reviewed multiple staff and client records/files. Clients were not present and were at day program when inspections was conducted therefore no clients were interviewed. LPA’s interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas.

No deficiencies were observed or cited during the annual inspection.

An exit interview was conducted with Freeman, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

LIC809 (FAS) - (06/04)

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