331800146-6-15-2023-18-AS-KBAG-CSTVPP-20230615163703

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800146
Report Date: 06/15/2023
Date Signed: 06/15/2023 04:37:13 PM

Document Has Been Signed on 06/15/2023 04:37 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CASA DE HARKNESS		FACILITY NUMBER:	331800146
ADMINISTRATOR:	ARMSTRONG, SUZANNE		FACILITY TYPE:	740
ADDRESS:	74050 SCHOLAR LANE WEST		TELEPHONE:	(760) 469-3656
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92211
CAPACITY:	6	CENSUS: 5	DATE:	06/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:34 PM
MET WITH:	Assistant administrator, Leslie Reyes		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that five (5) residents reside at this facility and there are currently (2) staff members present. The facility administrator’s assistant, Leslie Reyes came to conduct the facility tour. There is an Infection Control Plan on file. Client Records-Incident Reports/Clients Rights-Information/Dental- LPA began review of client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/and Staffing- LPAs began review of employee records- Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification. The administrator certification is current, Administrator, Suzanne Armstrong expiration date is 03/05/2024. Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen. (Continued on LIC809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CASA DE HARKNESS	FACILITY NUMBER: 331800146
	VISIT DATE: 06/15/2023

NARRATIVE

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(Continuation from LIC809)
Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 106.5 degrees F. Laundry facilities and a locked room is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA observed a facility phone, and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home. The fireplace is not operable and secured. The pool is secured by a 5-foot-high fence and was locked.
Medications- are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. Medications reviewed appear to have been dispensed accurately.
LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Nine (9) smoke detectors and carbon monoxide dual alarms were tested and found to be operational. There were one (1) fire extinguisher charged 01/23/2023. The administrator assistant stated that the last emergency disaster/ fire drill was done on 12/20/2022.

Based on the information received during this visit today in the areas reviewed, there are one (1) deficiency observed per Title 22, Division 6 of The California Code of Regulations Article 06. Background Check 87355 (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or Criminal Record Clearance
This LIC 809 and appeal rights was reviewed with and a copy will be provided to the administrator's assistant.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/15/2023 04:37 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CASA DE HARKNESS	FACILITY NUMBER: 331800146
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in allowing S2 to work at the facility for one (1) day without a criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/16/2023
	Plan of Correction
1 2 3 4	The administator assistant has agreed to read regulations 87355 entirely and send LPA a self-certify letter that the regulation was read and understood. The licensee has agreed to remove S2 from the facility and not allow S2 to work at the facility until S2 has a criminal background clearance. POC is due 06/16/2023

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

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