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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604223
Report Date: 09/25/2024
Date Signed: 09/25/2024 01:43:57 PM

Document Has Been Signed on 09/25/2024 01:43 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HOUSE OF J4FACILITY NUMBER:
374604223
ADMINISTRATOR/
DIRECTOR:		DIZON, JOSIEFACILITY TYPE:
735
ADDRESS:1215 FIRECREST WAYTELEPHONE:
(619) 200-6561
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 6CENSUS: 6DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Administrator, Josie DizonTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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On 9/25/2024, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator, Josie Dizon who was informed of the purpose of the visit. The facility has a fire clearance for six (6) ambulatory clients and serves adults ages 18 through 59. During the visit, there was three (3) staff and one (1) client present, and LPA was informed five (5) clients were attending day program.

LPA toured the facility and reviewed records. During the tour, LPA observed the facility is made up of a one (1) story home with three (3) client bedrooms, three (3) bathrooms, two (2) staff rooms, three (3) living rooms, a kitchen, dining room and attached garage. Indoor and outdoor pathways were free of obstructions. LPA toured the kitchen and observed the facility has more than a 2-day supply of perishable foods and 7-day supply of non-perishable foods, all stored in a safe and healthful manner. LPA toured the facility's exterior and observed outdoor shaded seating is available for the clients in care. No bodies of water were observed on the premises. Medications are stored in a cabinet in one (1) of the living rooms and secured with a master lock. LPA observed several board games and activities available for the clients in care. LPA reviewed the facility's Fire and Safety Records and noted the facility's last fire drill was conducted on 7/28/2024. LPA and Administrator Dizon reviewed the physical medications for two (2) clients along with their Medication Administration Record for September 2024 and did not discover any discrepancies. Administrator Dizon also tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed a charged fire extinguisher mounted in the kitchen, last serviced on 5/2/2024. Staff present have a criminal record clearance. LPA reviewed two random (2) client files, which had all Departmental required records including updated Individual Program Plans. LPA reviewed the Record Of Client's/Resident's Safeguarded Cash Resources (LIC 405) for two (2) clients while Administrator Dizon counted their physical monies and no discrepancies were discovered. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Dizon.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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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