374604397-6-15-2021-08-AS-DCOA-C3ZMGC-20210615093540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604397
Report Date: 06/11/2021
Date Signed: 06/15/2021 09:35:53 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	CHAPARRAL HOME CARE		FACILITY NUMBER:	374604397
ADMINISTRATOR:	JENKINS, BETHANY		FACILITY TYPE:	735
ADDRESS:	7256 VOLCLAY DR.		TELEPHONE:	6196642625
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92119
CAPACITY:	4	CENSUS: 0	DATE:	06/11/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Administrator, Bethany Jenkins and Chief Executive Officer (CEO) Deborah Jenkins		TIME COMPLETED:	12:40 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), Debbie Correia, conducted an announced Pre-licensing and Component IIl visit at an Adult Residential Facility (ARF) to ensure compliance with California Code of Regulations, Title 22, Division 6 and the Health and Safety Code. LPA Correia identified herself to Applicant Bethany 'Elise' Jenkins and Co-applicant Deborah Jenkins and explained the purpose of the visit. The application is to serve four (4) Developmentally Disabled (DD) adults, ages 18 - 59, all of whom must be ambulatory. The San Diego Fire Department granted Fire Clearance on March 15, 2021. During today's visit LPA Correia, accompanied by Administrator Jenkins and CEO Jenkins, conducted a tour of the facility. According to Administrator Jenkins, there will be no firearms or ammunition stored on site. No pools or bodies of water were observed. Indoor and outdoor passageways are free from obstructions. All window screens are clean and in good repair. Hallways are well-lit and night lights are available in the hallways. Fire, smoke alarms, and carbon monoxide detectors were all observed and operational. There is a bed for each resident's bedroom, equipped with padded covered mattresses, and pillows, observed clean and in good repair. There is sufficient closet and drawer space for resident belongings. Each resident bedroom is furnished with a chair, lamp, and a night stand. Resident bathrooms are also in good repair, equipped with handrails, Administrator provided proof of purchase of non-skid shower mats. The facility maintains a sufficient supply of clean linens, sheets, bedspreads, blankets, pillowcases, mattress covers, hand towels, and washcloths. LPA Correia observed a seven-day supply of non-perishable foods and a sample of the facility meal menu. The facility kitchen also maintains sufficient amounts of clean utensils, and equipment for proper storage of food items, and locked storage for sharp items (i.e. knives). LPA Correia observed an office for administrative staff that has a confidential storage area for personnel and resident records, as well as a locked storage cabinet for residents' medications. Emergency exit plans, facility policy, and residents' personal rights are posted in prominent areas. There is a shaded outdoor activity space, a common room available for visitors, and appropriate activity supplies.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CHAPARRAL HOME CARE	FACILITY NUMBER: 374604397
	VISIT DATE: 06/11/2021

NARRATIVE

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LPA observed a first aid manual and kit maintained at the facility. The facility garage remains locked when not in use and also has a locked laundry area to store cleaning supplies and other toxic chemicals. There is an operating telephone land line. There is emergency lighting and supplies readily available for safety measures. The hot water temperature measured at 106.1 and 108.2 degrees F in facility bathrooms, and the central air unit will be monitored to remain with in regulation compliance. Administrator's Certification expires on January 22, 2022 .

Component III was completed with the facility Administrator via telephone. LPA Correia reviewed continuing operational requirements, as well as record keeping and physical plant compliance with Administrator Jenkins. The applicant shall contact the Centralized Application Bureau (CAB) for completion of this pending facility application. Based on today's evaluation, the facility is in compliance with CCR, T22 and the Health and Safety Code. Final approval is forwarded to management pending review. Pre-licensing inspection is complete and the facility has no deficiencies.

An exit interview was conducted, and a copy of this report, and Licensee's Rights (9058 01/16) will be sent to the Administrator's e-mail address. An electronic mail read receipt confirms delivery of these documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

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