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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603269
Report Date: 09/06/2023
Date Signed: 09/06/2023 04:37:30 PM

Document Has Been Signed on 09/06/2023 04:37 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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:
09/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jayme Covarrubias, House ManagerTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA), Jacqueline Shaw Ross made an unannounced visit to the facility to conduct an annual licensing inspection. LPA identified herself and was granted entry into the facility by Jayme Covarrubias, House Manager. The facility is licensed to serves four (4) developmentally disabled adults. Two (2) of whom may be non-ambulatory. There is an incontinence plan on file. At the time of visit, there were three (3) staff and three (3) clients present.

A tour of the facility was conducted inside and out. The facility is a one story five (5) bedroom, three (3) bathroom home. Each client has their own bedroom and closet. One bedroom is reserved for live-in staff, the other bedroom is currently vacant. The facility temperature was 70 degrees during time of visit. The facility has one or more functioning carbon monoxide/smoke detector. Disinfectants, cleaning solutions, and poisons are locked and were observed inaccessible to consumers. Hot water temperature measured at over 120 degrees F for the bathrooms used by the clients. LPA recommended hot water temperature be lowered. House Manager adjusted water temperature to 120 and will continue to monitor it. All toilets, hand washing, and bathing facilities were observed in sanitary condition with available grab bars and non-skid mats or strips. LPA observed linens clean and in good repair. Lamps or lights are provided in all rooms. All of the clients rooms had the required furnishings. The facility is in good repair and has the required furnishings throughout. Required postings such as Emergency exiting plans, telephone numbers and Ombudsman information and other signage are posted throughout the facility.

LPA observed the entire kitchen, food is stored properly and dishes are clean and in good condition. There is a sufficient supply of perishable and non-perishable foods. Area was observed to be clean and functional. All food was properly stored and made available to clients. Licensee has secured each client's personal property and cash resources and was observed accurate. All outdoor/indoor passageways were observed free from obstruction.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NALAS RES.FAC. JACLYN'S HOME
FACILITY NUMBER: 374603269
VISIT DATE: 09/06/2023
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Medications were observed to be labeled and in a locked place that is inaccessible to clients. All staff subject to a criminal record review obtained criminal background clearance and/or an exemption. Staff responsible for direct care and supervision have current First Aid/CPR training. There are no firearms on the premises. Fire drills are conducted monthly. Last fire drill was conducted on 8/10/2023. Each client has a written admission agreement, needs and service plan, and physician’s report on file. Administrator Certificate for Huber Barquero expires on 1/6/2024.

Based on today’s inspection, No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted and a copy of this report was provided to House Manager, Jayme Covarrubias.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
LIC809 (FAS) - (06/04)
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