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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603269
Report Date: 09/23/2024
Date Signed: 09/23/2024 12:52:06 PM

Document Has Been Signed on 09/23/2024 12:52 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:NALAS RES.FAC. JACLYN'S HOMEFACILITY NUMBER:
374603269
ADMINISTRATOR/
DIRECTOR:		HUBER BARQUEROFACILITY TYPE:
735
ADDRESS:276 N WISCONSIN STTELEPHONE:
(760) 728-2671
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 4CENSUS: 3DATE:
09/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Caregiver, Renso EstradaTIME VISIT/
INSPECTION COMPLETED:
01:00 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
On 9/23/2024, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Caregiver, Renso Estrada who was informed of the purpose of the visit. The facility has a fire clearance for two (2) ambulatory clients and two (2) non-ambulatory clients, and serves adults ages 18 through 59. During the visit, there was three (3) staff and three (3) clients present.

LPA toured the facility and reviewed records. During the tour, LPA observed the facility is made up of a one (1) story home with four (4) client bedrooms, (3) bathrooms, a staff room, living room, kitchen, dining room and attached garage. LPA observed charged fire extinguishers mounted throughout the facility. Indoor and outdoor pathways were free of obstructions. Outdoor shaded seating is available for the clients in care. No bodies of water were observed on the premises. LPA toured the kitchen and observed the facility has more than a 2-day supply of perishable foods and 7-day supply of non-perishable foods, which are stored in a safe and healthful manner. Medications are secured in a locked cabinet above the refrigerator. LPA reviewed the physical medications for two (2) clients along with their Medication Administration Record for September 2024 and did not discover any discrepancies. Staff present have a criminal record clearance and were associated with the facility. LPA reviewed two (2) random client files, which had all Departmental required records. LPA reviewed the Record Of Client's/Resident's Safeguarded Cash Resources (LIC 405) for all three (3) clients while Caregiver, Alejandra Llamasarez counted their physical monies, and LPA did not discover any discrepancies. LPA reviewed the facility's Fire Evacuation Drill Log, which noted the facility's last fire drill was conducted on 9/10/2024.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Caregiver Estrada.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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