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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881520
Report Date: 07/17/2024
Date Signed: 07/17/2024 03:04:09 PM

Document Has Been Signed on 07/17/2024 03:04 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:NORTH COUNTY VILLAFACILITY NUMBER:
371881520
ADMINISTRATOR/
DIRECTOR:		CID, MARI DEE SANDRA C.FACILITY TYPE:
740
ADDRESS:1519 ANTHONY HEIGHTS DRIVETELEPHONE:
(760) 317-5220
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 6CENSUS: 4DATE:
07/17/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Applicant, Sandra CidTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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On 7/17/2024, Licensing Program Analysts (LPAs), Janette Romero and Jaqueline Shaw Ross made an announced visit to conduct a pre-licensing evaluation and met with Applicant, Sandra Cid. The home is currently licensed as a Congregate Living Health Facility licensed by the Department of Public Health and looking into transitioning into a Residential Care Facility for the Elderly (RCFE). An initial application to operate an RCFE was received by the Central Applications Bureau (CAB) on 10/23/2023. Fire clearance was granted on 2/15/2024 for total capacity of six (6) non-ambulatory or bedridden residents.

LPA toured the facility with Applicant Cid. During the tour, LPA observed the facility is made up of a one (1) story home with five (5) resident bedrooms, one (1) staff room, two (2) bathrooms, a kitchen, dining room, living room, and attached garage. The facility has a central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Applicant Cid tested one (1) of the smoke alarm/carbon monoxide detectors and LPA observed it to be operational. Resident bedrooms are each furnished with a bed, chair, and night stand. Bathrooms have a working toilet, wash basin and have paper towels, toilet paper, and soap readily available. LPA toured the kitchen and observed the stove to be operational and refrigerator/freezer in working condition. The facility has a 2-day supply of perishable foods and 7-day supply of non-perishable foods along with adequate seating for meals for all residents. Medications and confidential files are secured in a kitchen cabinet. Additional clean linens and towels are stored in a hallway closet. A commercial washer, dryer and cleaning solutions are secured in the locked garage. The backyard is gated and there are no bodies of water observed on the premises. Indoor and outdoor pathways are free of obstructions. Let-Us-No poster, emergency phone numbers, current license, and exit route/maps are visibly posted near the entrance.

During today's visit, LPA did not observe any issues or concerns. Applicant is scheduled to attend COMP III at the Riverside Regional Office on 7/25/2024. Final approval of licensure will be determined by CAB.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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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