331800167-10-17-2024-18-AS-AZEO-DA5SL7-20241017135753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800167
Report Date: 10/17/2024
Date Signed: 10/17/2024 01:58:06 PM

Document Has Been Signed on 10/17/2024 01:58 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:	DULCE VILLA I		FACILITY NUMBER:	331800167
ADMINISTRATOR:	MODY, NIKUL		FACILITY TYPE:	740
ADDRESS:	66147 S AGUA DULCE DR		TELEPHONE:	7602517842
CITY:	DESERT HOT SPRINGS	STATE: CA	ZIP CODE:	92240
CAPACITY:	6	CENSUS: 4	DATE:	10/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Lorena Doguillen		TIME COMPLETED:	02:10 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Abdoulaye Zerbo and Armando Perez conducted an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPAs were greeted by administrator Lorena Doguillen, notified her of the purpose for the visit and were allowed to enter the facility to conduct the inspection. Licensee Mody Trupti joined at a later time and she was informed of the purpose of the visit.

Facility Overview: The facility is a single-story building with 4 residents bedrooms, 1 staff bedroom and 3 bathrooms. There is no gated pool and there are no firearms on the premises.

Infection Control: LPAs observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in kitchen cabinet under the sink and inaccessible to residents. The smoke detector and carbon monoxide detector were tested and were operational. LPAs observed fire extinguishers to be in compliance with the department requirements and with and expiration date of 4-11-25. LPAs observed the hot water temperature to meet requirements. The temperature was measured at various locations and averaged at 109.5°F.

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two day supply of perishable foods. LPAs observed many items of the non-perishable food in the pantry to be expired. When the items were taken out, the facility did not meet the required seven day supply of non-perishable foods. Licensee informed LPA's a staff member was currently grocery shopping and will replace and restock the items needed to be in compliance. The violation will be addressed

Continued on LIC809-C.....

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Abdoulaye Zerbo	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

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: DULCE VILLA I	FACILITY NUMBER: 331800167
	VISIT DATE: 10/17/2024

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Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of April 27^th, 2025 and a CPR certification with expiration date of 10-25-25.

Record Review and Resident/Staff Files: LPAs reviewed files for three staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Four residents’ files were reviewed and contained all required documentation. LPAs observed Staff, resident files, first aid kit were locked in a cabinet in the hallway, emergency food and water were stored in the garage and the PPEs were stored by the front door.

Health-Related Services/Incidental Medical Services: All residents' medications were securely locked located in the hallway cabinet.

Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 8-6-2024, which met department requirements. All facility exits were clear of obstructions except one(1) non-ambulatory room where a recliner was blocking the exit door. Staff instantly relocated the recliner to meet compliance. A technical violation will be addressed for documentation purposes

One (1) deficiency was cited during the visit and a technical violation was issued. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Mody Trupti along with the appeal right.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Abdoulaye Zerbo	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/17/2024 01:58 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: DULCE VILLA I	FACILITY NUMBER: 331800167
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

87555(a)(b)(8)

This requirement is not met as evidenced by: Observation of multiple expired non perishable items in the pantry and the lack of 7 day required supply. Licensee informed LPAs that a staff member was currently grocery shopping and on their way back with groceries and non perishable items to meet the required 7 day supply of non perishables.
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in 5 items in the pantry which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/17/2024
	Plan of Correction
1 2 3 4	Licensee will check on expiration date of food items more often and keep in stock the required 7 day supply of non perishables.

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: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Abdoulaye Zerbo	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

LIC809 (FAS) - (06/04)

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