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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604427
Report Date: 06/17/2023
Date Signed: 06/17/2023 07:53:06 PM

Document Has Been Signed on 06/17/2023 07:53 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:SACRED HEART HOME CARE 2FACILITY NUMBER:
374604427
ADMINISTRATOR:IMSON, EMMAFACILITY TYPE:
735
ADDRESS:823 CAMELLIA STTELEPHONE:
(858) 722-5094
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 4CENSUS: 4DATE:
06/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Emma Imson, LicenseeTIME COMPLETED:
07:55 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived at the facility to conduct an annual inspection. LPA met with caregiver, Teofila Baez. Licensee Emma Imson arrived shortly. LPA explained the purpose of the visit and was granted entry into the facility. Present at the facility were two clients and two staff. The facility is a one story, four (4) bedroom two (2) bathroom home. The facility was inspected inside and out.

LPA conducted staff and client interviews. Staff and client records were also inspected. Staff present have criminal record clearances and are appropriately associated to the facility. The facility appears clean and free of odors. Client bedrooms are clean and appropriately furnished. Food supplies are sufficient. LPA observed all toxic chemicals and other hazards secured and inaccessible to clients. Water temperature was measured and deemed appropriate at 110.8 degrees. Furniture in the facility is in good repair. Outdoor space is free of hazards.

LPA inspected medications and during the inspection, the LPA observed the following deficiencies:



-The facility had medication pills that were pre-prepared and stored in a cup - not in its original container.
-The facility had medication on hand, Lamotrigine that was not listed on MARS.
- MARS log showed bedtime medications were already initialed by Staff before it was given to clients.

Licensee has been advised that deficiencies will be cited at a later date. An exit interview was conducted with the Caregiver and Licensee, and a copy of this report was provided.

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SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2023
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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