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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604572
Report Date: 06/27/2023
Date Signed: 06/27/2023 02:51:56 PM

Document Has Been Signed on 06/27/2023 02:51 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
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: 4DATE:
06/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:ADMINISTRATOR, JENNIFER MCCOYTIME COMPLETED:
03:00 PM
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On June 27, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to conduct the required annual inspection. LPA Mixson met with Administrator, introduced herself, and stated the purpose of the visit.
LPA Mixson toured the facility, along with the Administrator, and inspected the inside and outside of the facility. The facility is five bedroom, two story home, with a two car garage. Currently there are four residents residing in the home, and two staff. Currently the Administrator, Licensee, and one staff are present for interview questions. There are three residents available for interview questions, and is on a outing. The facility has three and a half baths, a kitchen, dining room, and living room, activity room. Additionally, the facility has an activity room and a front yard and back yard.
Physical Plant: The physical plant, is in good condition, neat, and orderly. The lawns and shrubbery are well maintained. Outdoor and indoor passageways are free of obstruction on todays visit. Residents bedrooms have the required bedding and furniture; such as clean mattresses, night stands, storage space, and sufficient lighting. The facility thermostat was set to 75. All resident bedrooms were equipped with the required items. The Administrator tested the hot water temperature in the restroom and it tested 118. The restrooms were equipped with non-skid surfaces and grab bars. LPA Mixson observed the kitchen and dining area. The facility had a menu posted and available for review. Kitchenware was in good condition and stored safely. Emergency food and water were observed in the garage. LPA Mixson inspected the common areas. Smoke detectors are hard wired and are tested monthly and a log was provided for review. The fire extinguisher was in the green and had not been used. Carbon monoxide alarms, along with smoke detectors were observed, and showed a green light. There was a locked and centralized storage area for medications. Medications ordered through a pharmacy that utilizes bubble packs. The facility had a designated area for resident and staff files, and it was lockable. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There was adequate seating in the common areas and sufficient space for activities. LPA Mixson observed a monthly activity calendar. LPA Mixson reviewed three staff files, four resident files, and conducted three staff interviews and two resident interviews.
There were no regulation violations observed during todays visit.
An exit interview was conducted and a copy of this report , along with the LIC 811, was provided to Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023
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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