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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603300
Report Date: 08/30/2023
Date Signed: 09/06/2023 02:13:48 PM

Document Has Been Signed on 09/06/2023 02:13 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:BANYAN ARFFACILITY NUMBER:
374603300
ADMINISTRATOR:DARA CROWFACILITY TYPE:
735
ADDRESS:1323 BANYAN DRIVETELEPHONE:
(760) 728-1618
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 4CENSUS: 4DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:14 PM
MET WITH:Juan Carlos Arguello, CargiverTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Cheryl Goodrich conducted an unannounced annual visit. LPA met the caregiver, Juan Carlos Arguello at the front door and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for four (4) ambulatory residents with 4 ambulatory residents in care. All residents are at day program and currently not at the facility.
Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies.
Physical Plant and Environmental Safety: The facility temperature read at 73 degrees. The facility consists of four (4) resident bedrooms, and two (2) bathrooms, living room, kitchen, and backyard. The bedrooms are furnished with furniture, lamp, and closet space and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The living room and kitchen clean and clear of obstruction. The medications are stored in a locked cabinet in the kitchen and inaccessible to residents. The ARF and has a current fire clearance for the facility, smoke and carbon monoxide detectors and fire extinguishers and are in working order.

(Continued on LIC809-C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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: BANYAN ARF
FACILITY NUMBER: 374603300
VISIT DATE: 08/30/2023
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(Continued from LIC809)

Personnel Records-Training: The staff records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings.
Client Records-Incident Reports: The facility has pre-placement appraisals, functional assessments, identification and emergency information, telecommunication device information, placement referral, residential agreement, financial resources information, medical consent, and physician’s orders and physician reports, and additional assessments. The resident’s cash resources documentation and physical cash is present, and receipts are present and accounted for.
Client Rights-Information: The facility has client rights information posted in the facility.
Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available.
Health- Related Services: The facility is distributing the resident’s medications according to the regulations and documenting the distribution of medications in the medication logbook.
Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill and disaster drill was completed 08/24/23. The facility has emergency supply of food and water.
Summary: Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with caregiver, Juan Carlos Arguello and a copy of this report was printed Signature below confirms receipt of these rights.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
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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