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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800110
Report Date: 03/13/2024
Date Signed: 03/13/2024 12:32:18 PM


Document Has Been Signed on 03/13/2024 12:32 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:HAPPY NEST IVFACILITY NUMBER:
331800110
ADMINISTRATOR:CAMUA, GEORGEFACILITY TYPE:
740
ADDRESS:1725 N WHITEWATER CLUBTELEPHONE:
(760) 699-7922
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:6CENSUS: 5DATE:
03/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:George Camua, Administrator, Claire Itchon, Licensee/AdministratorTIME COMPLETED:
12:40 PM
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On 3/13/24 Licensing Program Analyst (LPA) Javina George made an unannounced case management deficiencies visit. LPA met with Claire Itchon, Licensee/Administrator. LPA was at the facility conducting a health and safety check and made the following observations:
The facility was observed to have operable utilities (gas, electric, both hot and cold water).
Emergency/disaster:
LPA observed for the smoke detectors to not be illuminating any light. The Administrator George removed the detectors and the detectors were observed to not connected properly with the wires, as the connector was separated from the device. Once connected properly the detectors were observed to be operable. The facility was noted to have one (1) operable carbon monoxide detector.

Food supply: the facility was observed to have a two day supply of perishable and 7 day supply of non perishable food items. LPA observed expired food for there to be three (3) bottles of salad dressing, six (6) bags of expired cereal, a box of mash potato flakes and package of expired cookies. The expired items were discarded at the time of LPAs visit , there will not a be deficiency cited.

Medication:
the facility has the proper sharps box, a full sharps box that hand needles sticking out was observed to stored outside on the top of the refrigerator, inside the locked garage. Per Administrator George the sharps are discarded when agency staff comes to the facility. Per George agency staff come weekly.

LPA observed for the facility to not have a separate refrigerator for medications that require refrigeration. The facility is storing resident medications in the main refrigerator in an unlocked drawer with the vegetables (covered up with the cabbage and lettuce). LPA observed for there a minimum of eight (8) medications such as suppositories, and liquid medications belonging to both current and former resident. A deficiency is being cited in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).
An exit interview was conducted as well as copy of this report, appeal rights and LIC9098 Proof of Corrections form was provided to Claire Itchon, Licensee/Administrator.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/13/2024 12:32 PM - It Cannot Be Edited

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: HAPPY NEST IV
FACILITY NUMBER: 331800110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2024
Section Cited
CCR
87465(h)(1)(A)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:
(1) Medications shall be centrally stored under the following circumstances: (A) The preservation of medicines requires refrigeration, if the resident
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The licensee agrees to obtain a separate refrigerator so that the for the medications that require refrigeration can be stored separately from the food. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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has no private refrigerator. This requirement is not met as evidenced by: The licensee did not properly store medications that require refrigeration. Instead the meds were mixed with the fresh vegetables. This posed a potential health safety, and personal rights to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
LIC809 (FAS) - (06/04)
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