331800168-10-27-2023-18-AS-JARA-CWZVXF-20231027164928

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800168
Report Date: 10/27/2023
Date Signed: 10/27/2023 04:49:36 PM

Document Has Been Signed on 10/27/2023 04:49 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 II		FACILITY NUMBER:	331800168
ADMINISTRATOR:	MODY, NIKUL		FACILITY TYPE:	740
ADDRESS:	66171 S AGUA DULCE DR		TELEPHONE:	(760) 251-4606
CITY:	DESERT HOT SPRINGS	STATE: CA	ZIP CODE:	92240
CAPACITY:	6	CENSUS:	DATE:	10/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Staff, Lorena Guillen		TIME COMPLETED:	05:00 PM

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On 10/27/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met Staff, Lorena Guillen, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (4) residents present.

The facility is a one story home with (6) bedrooms and (3) bathrooms and attached garage. No pools or firearms are at the facility. The residents served are elderly ages 60 and above. The facility residents are vendorized by Regional Center. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following:

Infection Control: The LPA observed hand washing stations with hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan to train and follow infection control guidelines.

Physical Plant: Physical plant was observed to be clean and in good repair. The indoor and outdoor areas were observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. See technical advisory note for item found unlocked. The smoke detector and carbon monoxide was operational, and the hot water temperature was recorded at 108.5F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. The facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DULCE VILLA II	FACILITY NUMBER: 331800168
	VISIT DATE: 10/27/2023

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Record Review and Resident/Staff Files: LPA reviewed staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. The listed administrator has proof of submitting an administrator's certificate. Resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All resident medication was locked in hallway closet. LPA reviewed resident medications, and found all medication was accounted for a had proper documentation and labeling.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The last fire drill was conducted 9/23/23. LPA observed emergency exits and emergency supplies.

An exit interview was conducted where this report was reviewed along with technical notes were reviewed and provided to staff, Lorena Guillen.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC809 (FAS) - (06/04)

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