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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604322
Report Date: 12/27/2024
Date Signed: 12/27/2024 02:20:24 PM

Document Has Been Signed on 12/27/2024 02:20 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: 4DATE:
12/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Licensee, Robert JazminTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 12/27/2024, Licensing Program Analyst (LPA), Janette Romero made an unannounced visit to the facility to follow up on an Unusual Incident/Injury Report (LIC 624) submitted by the facility involving Client 1 (C1) and Staff 1 (S1). LPA met with Licensee, Robert Jazmin who was informed of the purpose of the visit.

LPA toured the facility, conducted interviews, and obtained copies of pertinent records. The facility was observed to have more than a two-day supply of perishable foods and seven-day supply of non-perishable foods along with operating utilities. LPA did not observe any imminent health or safety concerns relative to the LIC624 involving C1 and S1. An exit interview was conducted and a copy of this report was reviewed and provided to Licensee along with a Confidential Names List (LIC811).
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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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