374604080-7-7-2023-18-AS-JSRS-CTJ5JD-20230707195946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604080
Report Date: 07/07/2023
Date Signed: 07/07/2023 07:59:52 PM

Document Has Been Signed on 07/07/2023 07:59 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 SUNSET		FACILITY NUMBER:	374604080
ADMINISTRATOR:	NAGHIBI, ALI		FACILITY TYPE:	740
ADDRESS:	1380 REES RD		TELEPHONE:	(714) 322-1910
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	6	CENSUS: 5	DATE:	07/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Elizabeth Rivera, Administrator		TIME COMPLETED:	08:00 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	On July 7, 2023, Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived unannounced at the above facility to conduct a required annual inspection. LPA Shaw Ross was greeted and granted entry by Caregiver, Brenda Catap. LPA Shaw Ross introduced self, and stated the purpose of the visit. Administrator, Elizabeth Rivera joined shortly. An overall tour of the facility was conducted inside and out. The facility is a one story, five (5) bedroom, three (3) bathroom home. At the time of the visit, five (5) clients and two (2) staff were present. LPA observed one (1) bedroom that is shared by two clients and remaining bedrooms are private. All bedrooms were clean and appropriately furnished. Furniture in the home is in good repair. Outdoor space is free of hazards. LPA observed a small room used for overnight staff and a small designated office area next to the kitchen. The facility appeared clean and free of odors throughout. All smoke and carbon monoxide detectors were tested and found operational. Food supplies are sufficient. Emergency food and water was stored in the kitchen. Hot water temperature was measured at 113 degrees Fahrenheit. LPA observed all toxic chemicals and other hazards secured and inaccessible to clients. Medications are centrally stored in a locked closet in the hallway. LPA inspected medications and during the inspection, the LPA observed the following deficiency: - The facility had medication on hand, such as, Ferosul- the facility did not have said medication on MAR list.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

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 SUNSET	FACILITY NUMBER: 374604080
	VISIT DATE: 07/07/2023

NARRATIVE

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LPA inspected the staff and client records. Staff files had criminal record clearances and the required documentation including First Aid Certifications and training documents. Client records contained required documents and current information. The facility is completing emergency drills on a quarterly basis. Staff and client interviews was conducted.

Based on observations made by LPA, the facility was cited and a deficiency was noted on LIC809D. An exit interview was conducted with the Administrator Elizabeth Rivera and a copy of this report, LIC809D, and appeal rights was provided.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/07/2023 07:59 PM - It Cannot Be Edited

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 SUNSET	FACILITY NUMBER: 374604080
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(d)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	The facility had Ferosul medication on hand but the facility did not have said medication on MAR list.
	POC Due Date: 07/21/2023
	Plan of Correction
1 2 3 4	Administrator will audit MAR list each time new prescriptions are received. Administrator will provide additional training to designated staff assigned to manage Medication record-keeping.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC809 (FAS) - (06/04)

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