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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881571
Report Date: 12/17/2024
Date Signed: 12/18/2024 07:56:55 AM

Document Has Been Signed on 12/18/2024 07:56 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:NORTH COUNTY CASAFACILITY NUMBER:
371881571
ADMINISTRATOR/
DIRECTOR:		CID MARI DEE SANDRAFACILITY TYPE:
740
ADDRESS:657 W 15TH AVETELEPHONE:
(442) 277-4360
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 6CENSUS: 0DATE:
12/17/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:12 AM
MET WITH:Licensee/Administartor, Mari Dee SandraTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA met with Licensee/Administrator, Mari Dee Sandra Cid. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 09/05/2024 for a total capacity of six (6) residents. Fire clearance was granted on 11/14/2024. LPA Kathleen Banrasavong observed the following:

Structure:
Facility is a one-story house. There are five (5) resident’s bedrooms, one (1) staff bedroom, one (1) staff bathroom, one (1) residents' bathroom, living room, dining area and kitchen. There was a separate two (2) car garage. There is not a pool.

Heating/Cooling System:
Central heating and air conditioning system are installed and operable. Temperature was set at 80 degrees.

Bedrooms:
Each resident bedroom #1, #2, #3, #4, #5 were in good repair. Five (5) bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and ten (10) operable dual smoke and carbon monoxide alarms and two (2) single carbon monoxide alarms.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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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: NORTH COUNTY CASA
FACILITY NUMBER: 371881571
VISIT DATE: 12/17/2024
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Bathrooms:
One (1) residents’ bathrooms have a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and hand soap dispensers. LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 105 degrees Fahrenheit.

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp drawer will be secured in a locked drawer located in the cabinet in the kitchen. There was adequate room for food storage. LPA observed the stove and microwave to be operational. Refrigerator/freezer were in working condition. Pantry had sufficient storage for non-perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in the closet adjacent to the living room. Laundry detergents and cleaning supplies were observed in a closet under the sink and laundry closet.

Living/Family room:
There was a living room with furniture for all clients.

Linens and Hygiene Supplies:
An adequate supply of linens and hygiene supplies was stored in a cabinet in the hallway of the residence.

Yards/Outside:
Patio table and chairs were observed in the front yard. There was a gate on the front left side of the facility and the entry to the driveway with a self-latching closure and a button to press for the doorbell.

Emergency Phone Numbers, and Exit Plan:
Facility sketches were observed posted at the exits in the house. Exit signage, Let-Us-No poster, Rights of Resident Council, Theft & Loss, Personal rights, Non-discrimination observed.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: NORTH COUNTY CASA
FACILITY NUMBER: 371881571
VISIT DATE: 12/17/2024
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General items:
Four (4) fire extinguishers was charged and located throughout the facility with signage; fire extinguisher were purchased on April of 2023 and October 2023. Client records will be stored in a locked cabinet. One (1) first aid kits with required components were observed. There was a locked area for medication storage. Emergency food and water supply was observed. Pre-Licensing is complete, and this facility has Pre-Licensing is complete, and this facility has zero (0) deficiencies that need to be corrected. An exit interview was conducted and a copy of this report was provided to the Licensee/Administrator, Mari Dee Sandra Cid.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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