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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881447
Report Date: 12/16/2024
Date Signed: 12/16/2024 12:02:34 PM

Document Has Been Signed on 12/16/2024 12:02 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:CASA ZAGARA INC.FACILITY NUMBER:
371881447
ADMINISTRATOR/
DIRECTOR:		DOKKEN, GENSKE BRIDGETTFACILITY TYPE:
740
ADDRESS:2043 VISTA VALLE VERDE DRTELEPHONE:
(760) 419-5665
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 6CENSUS: 4DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Licensee, Jesse MaderaTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Licensees Jesse Madera and John Prevel who were informed of the purpose of the visit. At the time of the visit there was (4) staff and (4) residents present.

The facility is a one story home with (4) bedrooms and (3) bathrooms for residents. No pools or firearms are being kept at the facility. LPA observed the following:

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents in pantry closet. The smoke detector and carbon monoxide was operational, and the hot water temperature 115F.



Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. The current administrator, possesses a current administrator's certificate.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 12/16/2024
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Record Review and Resident/Staff Files: LPA reviewed (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. (4) resident files were reviewed, and possessed all required paperwork. Technical note was documented for Resident whose LIC602 reflects a bedridden status, when based on observation and interview the resident is able to reposition themselves in bed. Recommendation was made for licensee to obtain an accurate LIC602 to reflect ambulatory status for the resident.

Health Related Services/ Incidental Medical Services: All resident medication was locked in closet. LPA reviewed resident medications for (4) residents and found all medication listed on MARS and accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill 12/2/2024, which met the department requirements. LPA observed all facility exits were clear from obstructions.

No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
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