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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603840
Report Date: 02/22/2023
Date Signed: 02/22/2023 03:20:22 PM

Document Has Been Signed on 02/22/2023 03:20 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: 3DATE:
02/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:14 PM
MET WITH:ADMINISTRATOR, ANDRES CASTRO.TIME COMPLETED:
03:38 PM
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On February 22, 2023, Licensing Program Analyst (LPA), Venus Mixson made an unannounced Case Management/ Health & Safety visit. LPA Mixson met with Administrator introduced self and stated the purpose of the visit.

LPA Mixson interviewed Administrator, requested and received pertinent documentation. Documents requested Physicians Report, Admissions agreement, IPPS Face sheet, medication sheet, and Client Profile.

LPA Mixson toured the facility with Administrator. No health or safety concerns observed. 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. All three residents later arrived home from the day program with staff.

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: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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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