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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603879
Report Date: 09/12/2023
Date Signed: 09/12/2023 05:10:13 PM

Document Has Been Signed on 09/12/2023 05:10 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:ADAM'S HELENA ARFFACILITY NUMBER:
374603879
ADMINISTRATOR:CROW, DARAFACILITY TYPE:
735
ADDRESS:4041 HELENA STREETTELEPHONE:
(760) 451-0536
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 4CENSUS: 4DATE:
09/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Sonia Villegas, House ManagerTIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted an unannounced annual required licensing inspection. LPA was greeted at the front door by House Manager, Sonia Villegas and explained the purpose of the visit. The facility is authorized for four (4) developmentally disabled clients, ages 18-59, of which two (2) may be non-ambulatory. No exceptions/waivers are in place. Surety bond is current. The Emergency Disaster Plan is current and was reviewed with the House Manager during the visit. At the time of visit, all four (4) clients were attending an outing in the community and two (2)staff were present. LPA toured the home inside and out with the House Manager.

The facility is a three (3) bedroom, two (2) bath residential home. The inspection included but was not limited to:

Physical Plant: Facility temperature was measured at 72 degrees. The last disaster/fire drill was conducted on 7/19/2023. LPA observed there are no bodies of water on the premises. House Manager also advised there are no firearms or ammunition stored on the property. There is one or more carbon monoxide/smoke detectors which meets statutory requirements and one working fire extinguisher. All outdoor/indoor passageways were free from obstruction. Disinfectants and cleaning solutions were inaccessible to clients and poisons were locked. Bathrooms were clean, and had a working toilet, wash basin, and grab bar in the shower. The facility has clean towels, blankets, and linen in good repair. Water temperature in bathrooms used by clients measured 111.7 degrees. Bedrooms were appropriately furnished and furnishings in good repair. The facility was appropriately furnished and in good repair throughout the house.

Food Service: Facility has a two-day supply of perishable and a seven-day supply of non-perishable food items. All food was properly stored and made available to clients.

Continued on LIC809-C
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023
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: ADAM'S HELENA ARF
FACILITY NUMBER: 374603879
VISIT DATE: 09/12/2023
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Continued from 809...

The kitchen was observed to be clean and organized with clean dishes, and utensils. Additional food and supplies are stored in a pantry by the laundry room.

Medication/Facility Records: Medications were observed to be labeled and in a locked place that is inaccessible to clients and appear to be given as prescribed by a physician. LPA reviewed six (6) staff records and five (5) client records. All records had the required documents and were up to date. All staff subject to a criminal record review obtained background clearance and/or an exemption, First Aid, criminal record clearance, criminal record statement, and personnel record. Licensee maintains medical assessments, admission agreements, resident appraisals, needs and services plans, and centrally stored medication with each client/authorized representative on file.

Cash resources, personal property, and valuables of clients are kept separate and intact. Administrator Certificate for Dara Crow is current and expires on 7/18/2025 and Huber Baquero’s Administrator certificate expires on 01/06/24. LPA verified if staff utilize emergency interventions and that proper training has been completed. A resident roster was obtained during the visit.

LPA interviewed staff present but was not able to interview clients due to their attendance at an outing.

Based on today’s visit, no deficiencies were observed. An exit interview was conducted with House Manager, Sonia Villegas and a copy of this report was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC809 (FAS) - (06/04)
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