331800167-10-19-2022-18-AS-CNWE-CKCNU5-20221019104546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800167
Report Date: 10/19/2022
Date Signed: 10/19/2022 10:45:51 AM

Document Has Been Signed on 10/19/2022 10:45 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:	DULCE VILLA I		FACILITY NUMBER:	331800167
ADMINISTRATOR:	MODY, NIKUL		FACILITY TYPE:	740
ADDRESS:	66147 S AGUA DULCE DR		TELEPHONE:	(760) 251-7842
CITY:	DESERT HOT SPRINGS	STATE: CA	ZIP CODE:	92240
CAPACITY:	6	CENSUS: 3	DATE:	10/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:48 AM
MET WITH:	Nikul Mody, Administrator		TIME COMPLETED:	10:50 AM

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), Chinwe Nwogene made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by caregiver Hilda Ramos who called Administrator, Nikul Mody on the phone. Nikul Mody arrived at the facility shortly after. LPA also met with Lead caregiver Lorena Guillen who was informed of the purpose of the visit. At the time of visit there was 3 staff and 3 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility inside and out with Lorena and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer and paper towels) in all restrooms. LPA did not observe any pools or bodies of water within the premises. The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be any event of COVID-19 related illnesses. The facility has a designated infection control lead. The facility also cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed PPE supplies. LPA was informed that no weapons or ammunition is maintained at the home. Administrator, Nikul was informed of the licensing fees due. Nikul stated a check has been mailed to the CDSS office weeks ago.

During the tour of the laundry room, LPA Nwogene observed cabinet with laundry detergents not adequately secured. The cabinet was immediately locked by caregiver, Hilda Ramos.

Therefore, based on the observations made during today’s visit, one #1 deficiency was cited per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted, and this reported was reviewed and provided along with appeal rights to Nikul Mody.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

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 10/19/2022 10:45 AM - 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DULCE VILLA I	FACILITY NUMBER: 331800167
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/20/2022
	Plan of Correction
1 2 3 4	Although the cabinet was immediately locked by caregiver, Hilda Ramos, Nikul Mody stated a statment of understanding of the regulation sited above will be provided to LPA by the POC due date 10/20/2022.

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: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2