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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603585
Report Date: 12/11/2023
Date Signed: 12/11/2023 03:21:25 PM


Document Has Been Signed on 12/11/2023 03:21 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ALVIN'S HOMECAREFACILITY NUMBER:
374603585
ADMINISTRATOR:JOHN BULAOROFACILITY TYPE:
740
ADDRESS:724 DRIFTWOOD LANETELEPHONE:
(760) 990-4694
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:6CENSUS: 5DATE:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:LEAD CAREGIVER, DANIEL MIRELLES TIME COMPLETED:
03:38 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 December 11, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the required annual inspection and met with the Lead Caregiver, Daniel Mireles. The LPA introduced herself and stated the purpose of the visit.

LPA Mixson toured the facility along with the Lead Caregiver, Daniel and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is licensed for 6 seniors but is currently operating at 5 seniors, and is located at 724 Driftwood Lane Fallbrook, CA. 92028. Physical Plant: The facility phone number is (760) 990-4694 and is operable. The LPA observed the resident's bedrooms and they are equipped with required furniture as per Title 22. The LPA inspected the facility restroom, and the hot water temperature tested within regulations. The restrooms were clean and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The LPA observed required postings such as "If you See Something, Say Something" and the "Personal Rights" postings were posted in a common area. The cleaning supplies and sharp items were kept locked and inaccessible to the residents. There was a designated storage space for the resident and staff files and it was locked. Medications: were locked and inaccessible to residents in care. The overall facility is clean, the furniture is in good condition. The facility air conditioning and other appliances were operable currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly. Care & Supervision Facility has sufficient staff, two at the time of this visit, and staff were attentive to the residents. Records Review: The LPA reviewed five resident files, and two staff files, and conducted two staff interviews and one resident interview due to the residents family visits, and resting. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit. An exit interview was conducted and a copy of this report was given to the Lead Caregiver Daniel Mireles.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023
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