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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604250
Report Date: 10/13/2023
Date Signed: 10/13/2023 04:31:04 PM

Document Has Been Signed on 10/13/2023 04:31 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:BUILDING INDEPENDENCE 1FACILITY NUMBER:
374604250
ADMINISTRATOR:SANCHEZ, JAQUELINEFACILITY TYPE:
735
ADDRESS:1965 PIZARRO LANETELEPHONE:
(858) 780-6695
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 4CENSUS: 3DATE:
10/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jaqueline Sanchez, AdministratorTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility for the purpose of an annual review. LPA was greeted by Administrator, Jaqueline Sanchez and explained the purpose of the visit. A tour of the facility was conducted inside and out. At the time of visit, all three clients were home and one additional staff was available. The facility is licensed for four (4) ambulatory clients ages 18 through 59 with Developmental Disabilities.

The facility is a four (4) bedroom two (2) bathroom two story home. Two (2) bedrooms are private and one (1) bedroom is shared.

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 items are kept inaccessible to clients. Hot water was tested at 114 degrees Fahrenheit. Backyard area is free from obstructions.

Kitchen/Food Service: LPA observed the entire kitchen, food is stored properly and dishes are clean and in good condition. There is a sufficient supply of perishable and non-perishable foods. Area was observed to be clean and functional.

Care & Supervision: Facility has sufficient care staff employed.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2023
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: BUILDING INDEPENDENCE 1
FACILITY NUMBER: 374604250
VISIT DATE: 10/13/2023
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Administration: Emergency exiting plans, telephone numbers and Ombudsman information and other required signage are posted throughout the facility. Drills are conducted monthly. The last drill was conducted on 10/2/2023.

Record Review and Client/Staff Files: LPA reviewed current staff and all staff have Criminal Background Clearance, current CPR/First Aid certification, and trainings are current. Client records were reviewed and contained required documents. IPP and Physician reports are current. LPA reviewed P&I logs, records are balanced. P&I funds are kept separately from facility funds.

Medication Review: LPA reviewed medication and medication log. Residents' 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 Administrator,
Jaqueline Sanchez.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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