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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604322
Report Date: 08/20/2024
Date Signed: 08/20/2024 03:37:24 PM

Document Has Been Signed on 08/20/2024 03:37 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:A&R RESIDENTIAL CARE LLCFACILITY NUMBER:
374604322
ADMINISTRATOR/
DIRECTOR:		JAZMIN, ROBERTFACILITY TYPE:
735
ADDRESS:934 N BEECH STREETTELEPHONE:
(858) 204-5715
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 4CENSUS: 3DATE:
08/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Administrator, Maly RaymundoTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 8/20/2024, Licensing Program Analysts (LPAs) Janette Romero and Debbie Palacios conducted an unannounced case management visit to follow up on the recent passing of Client 1 (C1). LPAs met with Caregiver, Marlon Banuelos and Administrator, Maly Raymundo who were informed of the purpose of the visit. Licensee, Alexander Raymundo was contacted over the phone and also informed of the purpose of LPAs' visit.
On 8/20/2024, the facility reported C1's death to Community Care Licensing via fax. LPAs toured the facility, conducted interviews, and obtained copies of pertinent documentation. Additional documentation was requested and will be emailed to LPAs by 8/22/2024. During today's visit, no imminent health or safety concerns were observed. An exit interview was conducted where this report was reviewed and provided to Administrator Raymundo.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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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