<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530186
Report Date: 07/08/2024
Date Signed: 07/08/2024 04:03:33 PM

Document Has Been Signed on 07/08/2024 04:03 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
, CA 92507
FACILITY NAME:PEPPERMINT RIDGEFACILITY NUMBER:
335530186
ADMINISTRATOR/
DIRECTOR:		BARRON, STEPHANIEFACILITY TYPE:
740
ADDRESS:648 LOCUST STTELEPHONE:
(951) 273-7320
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 4CENSUS: 0DATE:
07/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jessica Paz, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:15 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) conducted an announced Pre licensing visit 07/08/2024 at 09:08 AM. This is an announced Pre-Licensing visit conducted with Administrator Jessica Paz who assisted in the tour of inside and outside of facility and the evaluation. The follow up visit was made and observed the following.

The facility is a four (4) bedroom and two and a half (2 1/2) bathroom home with an attached garage. Facility tour reveals the physical plan meeting regulations. Water temperature 113.5 degrees. Facility has appropriate furnishings to meet the needs of the resident. Outdoor tour has shaded areas and free from obstructions. The facility has locked cabinets where medication, disinfectants, and other items that are to be inaccessible to clients are needed. The facility carbon monoxide and smoke detectors were tested and found to be in working order. On this date, a COMP III orientation was conducted.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, CCR. Based on the observations and evaluation of the facility this date, the facility’s ready for licensure.

Administrator will be notified once facility is licensed.

An exit interview was conducted, and a copy of this report (LIC809) was discussed and provided with Administrator Jessica Paz.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 3