374604225-9-28-2023-18-AS-JSRS-CW54JW-20230928190924

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604225
Report Date: 09/28/2023
Date Signed: 09/28/2023 07:09:29 PM

Document Has Been Signed on 09/28/2023 07:09 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:	LIFE SAVER PLACE OF ESCONDIDO II		FACILITY NUMBER:	374604225
ADMINISTRATOR:	LAYGO, MARY JANE E		FACILITY TYPE:	740
ADDRESS:	1890 LENDEE DR		TELEPHONE:	(858) 284-9114
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92025
CAPACITY:	6	CENSUS: 6	DATE:	09/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	05:05 PM
MET WITH:	Amy Rose Undag, Assistant Administrator		TIME COMPLETED:	07:10 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 (LPA) Jacqueline Shaw Ross arrived at the facility to conduct a required annual inspection. LPA was greeted by caregiver Froilan Resolme and explained the purpose of the visit. A tour of the facility was conducted inside and out. At the time of visit, there were six (6) clients home and two (2) staff present. Assistant Administrator Amy Rose Undag arrived shortly. The facility serves six (6) non-ambulatory elderly residents; ages 60 and above. Facility is also approved to provide hospice care for two (2) out of the six (6) clients. The facility is a six (6) bedroom three (3) bathroom one story home. Each client has a private bedroom. During the tour the following was observed: Clients bedrooms had the required furnishings and were observed to be in good condition. Bathrooms had required signage, hand rails, non-slip mats. Night-lights were observed in the hallways. Fixtures and furniture for an operational facility are present and in good repair. All passageways were free of obstructions, charged fire extinguishers and the fire alarm system was operable, medications are kept centralized and locked, hazardous chemicals are locked and inaccessible to clients. Hot water was tested at 107 degrees Fahrenheit. The indoor temperature in the facility is 76 degrees. Care & Supervision: Facility has sufficient care staff employed. Administration: Emergency exiting plans, telephone numbers and Ombudsman information and other required signage are posted throughout the facility. Drills are conducted quarterly. The last drill was conducted on 9/20/2023.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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: LIFE SAVER PLACE OF ESCONDIDO II	FACILITY NUMBER: 374604225
	VISIT DATE: 09/28/2023

NARRATIVE

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Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen.

Record Review and Client/Staff Files: LPA reviewed current staff and all staff have has Criminal Background Clearance, current CPR/First Aid certification, and trainings
are current. Client records were reviewed and contained required documents including current physician reports, admission agreements and care plans.

Medication Review: LPA reviewed medication and medication log. Client's' medications are being dispensed according to physician's orders.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted and a copy of this report was provided to Assistant Administrator Amy Rose Undag.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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