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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881447
Report Date: 12/08/2023
Date Signed: 12/08/2023 11:05:04 AM

Document Has Been Signed on 12/08/2023 11:05 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CASA ZAGARA INC.FACILITY NUMBER:
371881447
ADMINISTRATOR:DOKKEN, GENSKE BRIDGETTFACILITY TYPE:
740
ADDRESS:2043 VISTA VALLE VERDE DRTELEPHONE:
(760) 419-5665
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 6CENSUS: 0DATE:
12/08/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Jesse MaderaTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Janira Arreola conducted an announced visit to the home in order to conduct an initial pre-licensing inspection. LPA met with applicants: John Prevel, Jesse Madera and Administrator Bridgett Genske Dokken.

LPA conducted a walk through and reviewed the pre-licensing documents. The facility will serve elderly ages 60 and above. The fire clearance was approved from bedridden in Bedroom #1 and #4. The home is licensed for capacity of (6), (5) non-ambulatory, (1) of which may be bedridden.

The home is a one story home with attached garage, with (5) bedrooms, 1 staff office, (1) caregiver room and (2.5) bathrooms. No pools are present at the facility. LPA observed PPE equipment and hand washing stations in the facility. LPA observed the emergency supplies and emergency exits. The physical plant was observed to be in good repair and free of hazards. The bedrooms had the required furniture along with linens. The facility kitchen can prepare food in a clean and safe environment. The facility possessed requirement amount of emergency supplies. The smoke alarms were tested and observed to be operational. There are designated locked areas for resident medication and sharps hazardous objects. The hot water temperature was recorded in resident restroom at 115F, and the land line was operational at (760) 298-1489.

There are no objections for the applicant to proceed in the pre-licensing process. An exit interview was conducted with Jesse Madera where this report ad provided to them.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
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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