374604208-10-15-2024-08-AS-ADOO-DA3SP9-20241015140247

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604208
Report Date: 10/15/2024
Date Signed: 10/15/2024 02:03:06 PM

Document Has Been Signed on 10/15/2024 02:03 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:	LIBERTY TRANQUILITY		FACILITY NUMBER:	374604208
ADMINISTRATOR/ DIRECTOR:	CYNTHIA RUIZ		FACILITY TYPE:	737
ADDRESS:	1404 ASH STREET		TELEPHONE:	(760) 625-5106
CITY:	RAMONA	STATE: CA	ZIP CODE:	92065
CAPACITY: 4		CENSUS: 4	DATE:	10/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Cruz Mora Assistant Program Director		TIME VISIT/ INSPECTION COMPLETED:	11:55 AM

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 (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. LPA introduced herself and was granted entry into the facility by Ali Jaouhar, Lead BSP, to whom LPA disclosed the purpose of the visit. The Assistant Program Director, Cruz Mora, arrived a short time later. According to the facility’s license, the facility has a maximum capacity of four (4) clients, all of whom may be non-ambulatory. During today’s inspection, there were a total of four (4) clients in care. The facility is approved for delayed egress doors. LPA, accompanied by the Assistant Program Director, toured the interior and exterior of the facility, and inspected each room. The facility was clean and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors and equipment inspected 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, meetings, and client activities. The facility’s ambient internal temperature was 72 degrees Fahrenheit. Hot water temperature at sink accessible to clients measured at 118 degrees Fahrenheit. Refrigerator and freezer temperatures were within regulatory range. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked cabinets. (Continued on LIC809C)

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

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: LIBERTY TRANQUILITY	FACILITY NUMBER: 374604208
	VISIT DATE: 10/15/2024

NARRATIVE

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(Continued from LIC809)

No pools or bodies of water were observed on the premises. Per the program director, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, and facility telephone were in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and the interviews did not raise any significant licensing concerns. LPA reviewed records/files. Staff are current on training requirements. Client files contained required documents. Confidential records were stored in locked areas.

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

An exit interview was conducted with Cruz Mora, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

LIC809 (FAS) - (06/04)

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