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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603688
Report Date: 10/16/2024
Date Signed: 10/16/2024 11:27:10 AM


Document Has Been Signed on 10/16/2024 11:27 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:SAPPHIRE CHARDONNAYFACILITY NUMBER:
374603688
ADMINISTRATOR:NAGHIBI, ALIFACILITY TYPE:
740
ADDRESS:484 CHARDONNAY COURTTELEPHONE:
(760) 539-7791
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY:6CENSUS: 6DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Daphne Drapeau - AdministratorTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Administrator Daphne Drapeau who was informed of the purpose of today's visit. At the time of the visit there was three (3) staff and six (6) residents present. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. LPA observed outdoor furniture and shaded area for clients. Detergents, cleaning solutions, and sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements. 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.



LPA reviewed staff files and training. All staff have the required personnel records on file, health screening, criminal record clearance, and updated annual training. Four (4) resident files were reviewed and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and updated Physician's Report. The listed administrator possesses a current administrator's certificate that expires in 2026. Resident medication was centrally stored and locked in a closet located in the hallway. LPA reviewed medications prescribed to three (3) residents and found all medication with required labeling found to be in place. LPA reviewed the facility's emergency and disaster plan and infection control plan. Facility conducts quarterly fire drills with the last fire drill being conducted on 09/28/2024. All facility exits were clear from obstructions. LPA observed emergency supplies in the garage, a charged fire extinguisher, and first aid kit with all required items. No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Administrator Drapeau.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
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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