<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603269
Report Date: 10/25/2021
Date Signed: 10/25/2021 10:25:23 PM

Document Has Been Signed on 10/25/2021 10:25 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:NALAS RES.FAC. JACLYN'S HOMEFACILITY NUMBER:
374603269
ADMINISTRATOR:HUBER BARQUEROFACILITY TYPE:
735
ADDRESS:276 N WISCONSIN STTELEPHONE:
(760) 728-2671
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 4CENSUS: 3DATE:
10/25/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:Rosaura Estrada and Jayme Ponce De LeonTIME COMPLETED:
04:42 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Kristina Ryan conducted an unannounced case management visit. LPA was granted entrance by House Manager, Rosaura Estrada and met with Direct Service Provider, Jayme Ponce De Leon and Rosaura Estrada. LPA was granted entrance after disclosing the purpose of the visit.

This visit was initiated due to a death report received on October 17, 2021. The administrator was provided with LIC 811 - Confidential Names Form, in order to identify C1. During today's visit, LPA toured the facility, requested resident records, conducted interviews, and observed clients in care. No immediate health and/or safety concerns were observed during the visit.

No deficiencies were issued during today's visit. An exit interview was conducted with Jayme Ponce De Leon and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Administrator via email. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Kristina Ryan
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1