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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604508
Report Date: 03/05/2024
Date Signed: 03/05/2024 02:26:38 PM


Document Has Been Signed on 03/05/2024 02:26 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:COGIR OF FALLBROOKFACILITY NUMBER:
374604508
ADMINISTRATOR:ZEPEDA, JESSICAFACILITY TYPE:
740
ADDRESS:1735 SO MISSION ROADTELEPHONE:
(760) 232-6800
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:128CENSUS: 5DATE:
03/05/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jessica Zepeda, Executive DirectorTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit case management visit to the facility for the purpose of conducting a health and safety check. LPA met with Executive Director Jessica Zepeda, and explained the purpose of the visit. LPA requested and was provided copies of the staffing schedule for the month of March 2024, as well as an updated Register of Residents.

Per Jessica, on 3/1/24 the residents were provided a sixty (60) day notice in person, as well a copy via certified mail. As of today (3/5/24), there are five (5) residents remaining in care, with all but one (1) having an anticipated move out date on or before 3/17/24. There are three (3) residents in memory care, and two (2) residents in assisted living. The anticipated facility closure date is 4/15/24.

LPA conducted a tour of the interior and exterior of the facility , the facility was observed to be clean, have music playing and to be decorated for St. Patrick's Day. LPA observed for the facility food supply to be sufficient for the number of resident's in care, the facility has a 2 day supply of perishable and a 7 day supply of nonperishable food items.

The facility continues to have an adequate staffing levels, and the resources such as the residents prescribed medication, and paper supplies (paper towels and toilet paper). The facility was observed to have operable utilities, gas, water, and electric.

There were no health and safety concerns observed during today's visit.

An exit interview was conducted and a copy of this report, and LIC811 (confidential names) list was provided to Jessica Zepeda, Executive Director.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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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