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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603840
Report Date: 01/13/2023
Date Signed: 01/13/2023 01:51:11 PM

Document Has Been Signed on 01/13/2023 01:51 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:J & A CAREFACILITY NUMBER:
374603840
ADMINISTRATOR:DURAN, YESENIAFACILITY TYPE:
735
ADDRESS:779 OAK GLADE DRIVETELEPHONE:
(760) 645-3813
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 4CENSUS: 4DATE:
01/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:08 PM
MET WITH:ADMINISTRATOR, ANDRES CASTRO.TIME COMPLETED:
01:58 PM
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On January 13, 2023, Licensing Program Analyst (LPA), Venus Mixson made an unannounced Case Management/ Health & Safety visit. LPA Mixson was greeted and granted entry by Lead Caregiver introduced self and explained the purpose of the visit.
LPA Mixson later met with Administrator, Andres Castro requested and received pertinent documentation.
Other documentation will be scanned due to the amount of documents requested, by the close of business day Monday January,16, 2023. Documents requested IPP's for R1, for the years 2019, 2020, & 2021. R1's Physicians Report, any notes or SIR's from the years in question. Client Roster with date of births and responsible party.
LPA Mixson toured the facility inside and out. No health or safety concerns observed currently. Currently there were no residents home due to being at the Day Program. LPA Mixson observed two facility staff present at the time of the visit. There are no imminent health and/or safety concerns observed. LPA Mixson observed facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. All daily activities were going forth as usual without interruption. LPA Mixson assessed the available food supply and observed that the supply exceeds the requirement of a two day supply of perishable foods and a seven day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care.
An exit interview was conducted and a copy of this report, along with the LIC 811, was provided to Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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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