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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 02:19:42 PM

Document Has Been Signed on 12/27/2024 02:19 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 - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Licensee, Robert JazminTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 12/27/2024, Licensing Program Analyst (LPA), Janette Romero made an unannounced visit to the facility to address a deficiency observed during a case management visit at the facility on 12/27/2024. LPA met with Licensee, Robert Jazmin who was informed of the purpose of the visit.

During today's visit, LPA observed Client 1 (C1), Client 2 (C2), Staff 1 (S1), and Staff 2 (S2) present in the facility. LPA conducted a record review and discovered S1 did not possess a criminal record clearance or exemption to work or reside in the facility. Licensee was interviewed and reported S1 is a live-in staff and has been working as a caregiver in the facility providing care and supervision to the clients since 12/23/2024. S2 had a criminal record clearance. As a result, the facility was cited and assessed a civil penalty. An exit interview was conducted and a copy of this report was reviewed and provided to Licensee along with LIC 809-D, LIC421BG, and Appeal Rights.
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)
Page: 1 of 2
Document Has Been Signed on 12/27/2024 02:19 PM - It Cannot Be Edited


Created By: Janette Romero On 12/27/2024 at 01:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A&R RESIDENTIAL CARE LLC
FACILITY NUMBER: 374604322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/28/2024
Section Cited
CCR
80019(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement was not met as evidenced by:
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During the visit, Licensee escorted Staff 1 out of the building and reported the facility will not allow facility staff to work or reside in the facility prior to obtaining a criminal record clearance or exemption. POC cleared during the visit.
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During today's visit, LPA observed Client 1 (C1), Client 2 (C2), Staff 1 (S1), and Staff 2 (S2) present in the facility. LPA conducted a record review and discovered S1 did not possess a criminal record clearance or exemption to work in the facility. Licensee was interviewed and reported S1 is a live-in staff and has been working as a caregiver in the facility providing care and supervision to the clients since 12/23/2024. This poses an immediate health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
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