374604194-4-19-2024-08-AS-CLOZ-D4GQJE-20240419121238

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604194
Report Date: 04/19/2024
Date Signed: 04/19/2024 12:12:47 PM

Document Has Been Signed on 04/19/2024 12:12 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	WIND RIVER FAMILY CARE		FACILITY NUMBER:	374604194
ADMINISTRATOR:	PETROV, JULIAN		FACILITY TYPE:	735
ADDRESS:	2062 WIND RIVER ROAD		TELEPHONE:	(619) 447-2473
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92019
CAPACITY:	4	CENSUS: 4	DATE:	04/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Irina Tordorova, Administrator		TIME COMPLETED:	12:20 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’s (LPA’s) Carmen Lopez and Ryan Fulton conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPAs Lopez and Fulton identified themselves, were granted entry by Direct Support Personnel (DSP) Beatrice Acquah. LPAs discussed the purpose of the visit with DSP Beatrice Acquah. Administrator Todorova later arrived and joined the visit. According to the facility’s license, there may be a maximum of four (4) clients all of whom may be ambulatory in at any given time at the facility site. During today’s inspection, the facility’s current census is 4 clients living at the facility. There were no clients present at the facility site during the inspection. LPAs, accompanied by DSP Acquah, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, and activities. The facility’s ambient internal temperature was comfortable and compliant, at 71 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were also compliant: kitchen sink measured hot water temperature 108 degrees F; sink in restroom #1 delivered hot water at 115 degrees F; sink in restroom #2 delivered hot water at 117.5 degrees F; and sink in restroom #3 delivered hot water at 118.2 degrees F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/ and dining equipment and utensils were present, and all safely stored. There were no toxic chemicals/poisons accessible to clients. Medications were properly labeled, as required, and stored in locked areas. LPA inspected the medication cabinet and found that medications were properly labeled and stored and locked. The facility-maintained medication logs which LPA reviewed. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: WIND RIVER FAMILY CARE	FACILITY NUMBER: 374604194
	VISIT DATE: 04/19/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

There was a hot tub on the facility premises. The fence was in good repair, at least five feet high, and constructed with sufficient strength that it did not readily bend upon impact. The pool does have a self-latching locked fence. Per the Administrator, “Fencing will remain in place and properly functioning whenever there is a licensed client in care.” Per Administrator Todorova, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present (02) and serviced within the last 12 months. First aid kit was complete and readily accessible.

LPAs reviewed staff and client records. During today’s visit there were no clients on the facility premise. LPA’s tour did not raise any licensing concerns. The files which LPAs reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

There were no deficiencies observed or cited during today's annual inspection.

An exit interview was conducted with Administrator Todorova to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Administrator Todorova to submit their current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, Emergency Disaster Plan LIC 610-D, and Residential Infection Control Plan LIC 9282 (6/23), to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

LIC809 (FAS) - (06/04)

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