374603539-12-20-2024-18-AS-JARA-DC5QJN-20241220111301

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603539
Report Date: 12/20/2024
Date Signed: 12/20/2024 11:13:33 AM

Document Has Been Signed on 12/20/2024 11:13 AM - 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:	HOUSE OF J 2		FACILITY NUMBER:	374603539
ADMINISTRATOR/ DIRECTOR:	JOSIE DIZON		FACILITY TYPE:	735
ADDRESS:	1809 FALLBROOK OAKS COURT		TELEPHONE:	(442) 444-8362
CITY:	FALLBROOK	STATE: CA	ZIP CODE:	92028
CAPACITY: 6		CENSUS: 6	DATE:	12/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Licensee, Josie Dizon		TIME VISIT/ INSPECTION COMPLETED:	11:20 AM

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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Licensee, Josie Dizon, who was informed of the purpose of the visit. At the time of the visit there was (1) staff and (0) clients present. The clients were out in the community at the time of the visit.

The facility is a one story home with (3) bedrooms and (2) bathrooms for clients. No pools or firearms are being kept at the facility. The facility is an adult residential facility. LPA conducted a walk through, interviews and records review.

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility.

Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 105F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HOUSE OF J 2	FACILITY NUMBER: 374603539
	VISIT DATE: 12/20/2024

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Care & Supervision/Administration: LPA reviewed the staff scheduled showing adequate staff coverage. Required postings were found in the facility. The listed administrator, possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. (3) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in closet. LPA reviewed client medications for (3) client and found all medication listed on MARS and accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill 10/7/2024, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies such as a first aid kit.

No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC809 (FAS) - (06/04)

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