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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604572
Report Date: 05/27/2022
Date Signed: 05/27/2022 10:13:27 AM

Document Has Been Signed on 05/27/2022 10:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SANCHEZ RESIDENTIAL CARE 3FACILITY NUMBER:
374604572
ADMINISTRATOR:MCCOY, JENNIFERFACILITY TYPE:
735
ADDRESS:12764 CUMBRES ROADTELEPHONE:
(858) 335-3540
CITY:VALLEY CENTERSTATE: CAZIP CODE:
92082
CAPACITY: 4CENSUS: 0DATE:
05/27/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Isabel Sanchez, ApplicantTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an announced pre-licensing inspection at the facility and met with applicant, Isabel Sanchez.

Application: The application is for an Adult Residential Facility (ARF), Change of Location. The fire clearance has been granted for four (4) ambulatory clients.

Buildings and Grounds: The home is composed of three (3) client bedrooms, one (1) staff bedroom, three (3) bathrooms, a living room area, a laundry room, kitchen and dining areas, garage, and front/back yard areas. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors are in working order. There are no pools or other bodies of water located at the home. According to Sanchez, firearms will be kept in the home. Sanchez showed the LPA the two locations in which the firearms and ammunition will be stored separately. Bedrooms were in in excellent condition. Bedrooms are partially furnished and privacy is available. Per Sanchez, additional furniture will be brought from the previous location and photos verified furniture is available. The dining and living room areas are clutter free and in good condition. Outdoor areas had sufficient room for activities and leisure. A washing machine was available and a dryer will be made available upon transfer of location.

Storage and Supplies: Medications will be stored in a locked closet, inaccessible to any unauthorized individuals. Secured areas will be made available for facility files and client files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored away in the laundry room. Linens and equipment appeared to be in good repair. Fire extinguishers were available and fully charged.

Food Service: Utensils and dishware are sufficient for the requested capacity, and additional supplies will be brought from the other home. The refrigerator and stove are in working order. Sharps will be stored in a locked closet, available only to authorized individuals.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SANCHEZ RESIDENTIAL CARE 3
FACILITY NUMBER: 374604572
VISIT DATE: 05/27/2022
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Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610E), Personal Rights and Facility Sketch (LIC 999). Additional signs will be posted upon licensure.

No needed corrections were observed to be needed at time of visit. The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensure. This report was discussed with and a copy provided to the applicant.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC809 (FAS) - (06/04)
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