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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880550
Report Date: 02/28/2025
Date Signed: 02/28/2025 12:53:25 PM

Document Has Been Signed on 02/28/2025 12:53 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:COTTAGES AT PALM SPRINGSFACILITY NUMBER:
331880550
ADMINISTRATOR/
DIRECTOR:		EDDY, TAMMYFACILITY TYPE:
740
ADDRESS:1780 E BARISTO RDTELEPHONE:
(760) 322-3444
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY: 95TOTAL ENROLLED CHILDREN: 0CENSUS: 74DATE:
02/28/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Executive Director, Tammy EddyTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to cite for a case management deficiencies, on a visit regarding the health, safety, and welfare of residents in care. During the Department's investigation for complaint control number #18-AS-20240515085438. The Department discovered that the facility failed to submit a serious incident report to the department. The Facility failed to show proof that there was any attempts made to notify the department of the incident where R1 had a fall on 08/13/22 and went to the hospital. Executive Director, Tammy Eddy stated to LPA Banrasavong the facility had no record of the incident via email correspondence, of any proof of any Serious Incident Reports (SIRS) submitted to Licensing. This is a violation of Title 22 Regulations Reporting Requirements.

LPA toured the facility and observed all facility utilities to be on and operating without issues. Food supply is sufficient. There is no immediate concern for residents in care at this time.

There is one (1) deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted, a copy of this report, the 809-D, an 811, and appeal rights were provided to the Executive Director, Tammy Eddy.

Jazmond D HarrisTELEPHONE: (951) 248-0318
Kathleen BanrasavongTELEPHONE: 951-622-3619
DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2025
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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Document Has Been Signed on 02/28/2025 12:53 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: COTTAGES AT PALM SPRINGS
FACILITY NUMBER: 331880550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2025
Section Cited
CCR
87211(a)(1)

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REPORTING REQUIREMENTS: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to...: (1) A written report shall be submitted to the licensing agency... within 7 days of the occurrence of any of the events specified in (A) through (D)...
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The Execcutive Director, Tammy Eddy reported staff training regarding reporting requirements will be conducted and proof submitted to the Department by COB on the POC due date.
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This requirement was not met, as evidenced by: Based on record review the licensee did not ensure a written report was submitted within 7 days regarding R1's elopment from the facility. This poses a potential threat to the health, safety and personal rights of the resident 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.
Jazmond D HarrisTELEPHONE: (951) 248-0318
Kathleen BanrasavongTELEPHONE: 951-622-3619

DATE: 02/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2025

LIC809 (FAS) - (06/04)
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