374603699-10-9-2023-18-AS-JSRS-CWFR4P-20231009124153

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603699
Report Date: 10/09/2023
Date Signed: 10/09/2023 12:45:01 PM

Document Has Been Signed on 10/09/2023 12:45 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:	SAPPHIRE LAKE SAN MARCOS		FACILITY NUMBER:	374603699
ADMINISTRATOR:	MATIC, VICTORIA		FACILITY TYPE:	740
ADDRESS:	839 LA TIERRA DRIVE		TELEPHONE:	(760) 471-1157
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92078
CAPACITY:	6	CENSUS: 5	DATE:	10/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Elizabeth Rivera		TIME COMPLETED:	12:45 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	Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility for the purpose of an annual review. LPA was greeted by Caregiver, May David and explained the purpose of the visit. Administrator Elizabeth Rivera arrived shortly. A tour of the facility was conducted inside and out. At the time of visit, there were three (3) clients home and three (3) staff available. Administrator informed LPA that two of the clients were currently in day program. The facility is a five (5) bedroom two (2) bathroom one story home. Two bedrooms are private, two bedrooms are shared two to a room. One bedroom is reserved for live in staff. During the tour the following was observed: Clients bedrooms had the required furnishings and were observed to be in good condition. Bathrooms had required signage, hand rails, non-slip mats. Night-lights were observed in the hallways. Fixtures and furniture for an operational facility are present and in good repair. All passageways were free of obstructions, charged fire extinguishers and the fire alarm system was operable, medications are kept centralized and locked, hazardous items are kept inaccessible clients. Hot water was tested at 113.7 degrees Fahrenheit. Backyard area is free from obstructions. Kitchen/Food Service: LPA observed the entire kitchen, food is stored properly and dishes are clean and in good condition. There is a sufficient supply of perishable and non-perishable foods. Area was observed to be clean and functional. Care & Supervision: Facility has sufficient care staff employed. Administration: Emergency exiting plans, telephone numbers and Ombudsman information and other required signage are posted throughout the facility. Drills are conducted monthly. The last drill was 9/30/2023. The Administrator's certificate expires 6/9/2024.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

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: SAPPHIRE LAKE SAN MARCOS	FACILITY NUMBER: 374603699
	VISIT DATE: 10/09/2023

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Record Review and Client/Staff Files: LPA reviewed current staff and all staff have Criminal Background Clearance, current CPR/First Aid certification, and trainings are current. Client records were reviewed, contained required documents and records are up to date.

Medication Review: LPA reviewed medication and medication log. Client's medications are being dispensed according to physician's orders.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted and a copy of this report was provided to Administrator,
Elizabeth Rivera.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

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