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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603481
Report Date: 01/24/2024
Date Signed: 02/08/2024 07:20:48 PM

Document Has Been Signed on 02/08/2024 07:20 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:MARYAM ARFFACILITY NUMBER:
374603481
ADMINISTRATOR:LEEDA DOSTFACILITY TYPE:
735
ADDRESS:9319 NORTHVIEW TERRACETELEPHONE:
(858) 348-7247
CITY:SANTEESTATE: CAZIP CODE:
92071
CAPACITY: 6CENSUS: 6DATE:
01/24/2024
TYPE OF VISIT:Case Management - Annual ContinuationANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Administrator Assistant Elizabeth GuthTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Correia conducted an unannounced visit to conclude the annual inspection initiated on January 17, 2024. LPA was met by Administrator Assistant Guth, identified herself, was granted entry into the facility, and stated the purpose of today’s visit.

During today's visit LPA Correia, accompanied by Administrator Assistant Guth, observed the facility's temperature measured at 72 degrees Fahrenheit. The hot water temperature, from faucets used by clients in care, measured between 110.5- and 115.0-degrees. Disinfectants, cleaning solutions, and poisons were inaccessible to clients. Client bedrooms were equipped with the required furnishings and linens, and sanitary. Client bathrooms were observed to be sanitary, in good repair, and the shower/bathtubs had nonskid flooring and grab bars. LPA observed the facility had an adequate supply of clean linens in good repair and sufficient hygiene products for personal use.

During today's visit all smoke and carbon monoxide detectors were in operable condition. Per, Administrator Assistant Guth, the facility has no ammunition or weapons, or bodies of water, on the premises. The facility was stocked with a 2-day supply of perishable and 7-day supply of nonperishable food items. The food was observed properly stored. Medications are stored in a locked cabinet and administered according to the label instructions. The facility's last disaster drill was conducted on November 1, 2023. Per staff records reviewed, individuals subject to a criminal record review obtained clearance; staff responsible for direct care and supervision have current First Aid and CPR training. Administrator certification was also current.

Based on today's visit, there were no deficiencies observed during today's annual inspection continuation visit in the areas evaluated. An exit interview was conducted, and a copy of this report will be provided. Signature below confirms receipt of the documents.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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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Document Has Been Signed on 02/08/2024 07:20 PM - It Cannot Be Edited


Created By: Debbie Correia On 01/24/2024 at 02:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MARYAM ARF
FACILITY NUMBER: 374603481

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
80020 Fire Clearance: “(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshall.”

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the Licensee did not comply with the section cited above by not securing and maintaining a fire clearance approved by the servicing city or county fire department or State Fire Marshall. Smoke detectors were observed to be inoperable during the inspection on January 17, 2024, which posed an immediate safety risk to 6 persons in care.
POC Due Date: 01/17/2024
Plan of Correction
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Licensee Dost replaced all smoke detectors during the visit on January 17, 2024. LPA observed all smoke detectors to be in operable condition prior to departure from the visit. POC is cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Simon Jacob
LICENSING EVALUATOR NAME:Debbie Correia
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024


LIC809 (FAS) - (06/04)
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