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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604496
Report Date: 03/23/2022
Date Signed: 03/23/2022 11:21:46 AM

Document Has Been Signed on 03/23/2022 11:21 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ARNICARE VILLAFACILITY NUMBER:
374604496
ADMINISTRATOR:MONTAZER, ARNIFACILITY TYPE:
740
ADDRESS:1044 JESSICA LANETELEPHONE:
(858) 382-1568
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 0DATE:
03/23/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Arni & Hamid Montazer, Licensee'sTIME COMPLETED:
11:40 AM
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On 03/23/22 Licensing Program Analyst (LPA) Javina George conducted an announced pre-licensing inspection. LPA met with Administrator Arni and Hamid Montazer Currently there are 0 residents in care. The application is for a Residential Care for Elderly (RCFE) with a capacity of six (6) residents. On 02/22/22, the Escondido Fire Department approved the facility for 5 non-ambulatory residents and 1 bed ridden resident. The bedridden resident will reside in bedroom number one (1), which is a shared room. The facility does have an approved hospice waiver for six (6) and will retain residents whom have a mild cognitive impairment diagnosis.

A tour of the interior and exterior was conducted. The facility is a single story, five (5) bedroom, one of which is designated for a live in caregiver. There are three (3) bathrooms home with a living room, family room, dining room and kitchen. There is a pool, surrounded by a locked fence. There are no firearms or ammunition stored at the facility. LPA observed the bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, shower and tubs have grab bars and non-skid mats. Hot water in the resident’s bathrooms were measured at 109 to 113 degrees F.

LPA observed food storage and preparation areas. Food preparation areas are clean and sanitary. Refrigerator and freezer are maintained at appropriate temperatures. The kitchen was observed to have dishes, silverware and pots and pans. There is enough for the approved capacity. All appliances are clean and are operable.

There is a sufficient supply of linens, towels and personal hygiene items. The facility has a brand new first aid kit. LPA observed a recreation area with leisure items Garden, board games, puzzles, word search and record player.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ARNICARE VILLA
FACILITY NUMBER: 374604496
VISIT DATE: 03/23/2022
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Outdoor space is suitable for resident use and was observed to be fully fenced with an unlocked gate. The facility has taken extra security measures and has an alarm system, with a front door security camera.

The fire extinguishers (2) are completely charged. The facility is equipped with fire doors, smoke alarms and carbon monoxide detectors are present and operable. Resident and staff files and medications will be locked in the closet inside of the living room.

All hazardous materials such as, cleaning and disinfecting supplies are locked inside cabinets located inside of the laundry room. The knives, and other sharps are locked and inaccessible to residents inside a drawer inside of the kitchen. across from the refrigerator. All required forms such as resident rights, CCL complaint poster, Emergency disaster plan, Ombudsman poster and Covid-19 postings are posted throughout the facility.

Pre-licensing inspection complete. Composition III orientation was completed immediately following the inspection. Facility is ready for licensure. An exit interview was conducted, and a copy of this report was reviewed and provided to Arni & Hamid Montazer.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC809 (FAS) - (06/04)
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