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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880654
Report Date: 06/28/2022
Date Signed: 06/28/2022 03:07:17 PM

Document Has Been Signed on 06/28/2022 03:07 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ASSURANCE HOME 1FACILITY NUMBER:
331880654
ADMINISTRATOR:ARDEN ZALSOSFACILITY TYPE:
740
ADDRESS:627 HIGHLAND DRTELEPHONE:
(760) 537-1969
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92264
CAPACITY: 9CENSUS: 6DATE:
06/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:43 PM
MET WITH:Caregiver Segundina "Connie" EdwardsTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA), Jesse Gardner, conducted an unannounced visit to the facility to initiate the investigation into complaint #18-AS-20220628080253. LPA identified himself and discussed the purpose of the visit with caregiver Segundina "Connie" Edwards. LPA had been made aware that staff had not been paid.

LPA interviewed S1, and S2. S1 indicated that the last time they were paid was approximately 6/10/22. S2 indicated that staff are paid on the 15th and 30th of each month. Interviews with S1 revealed that they were deficient money from a total of 15 days in March, 2022. Deficiency cited.

An exit interview was conducted and a copy of this report along with a copy of the LIC811, and LIC809-D was discussed with and provided to Caregiver Segundina "Connie" Edwards.




SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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 06/28/2022 03:07 PM - It Cannot Be Edited


Created By: Jesse Gardner On 06/28/2022 at 02:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ASSURANCE HOME 1
FACILITY NUMBER: 331880654

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2022
Section Cited
CCR
87213

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Finances- The licensee shall have a financial plan...that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and...submit such financial reports...upon the written request of the licensing agency. This requirement was not met as evidenced by:
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Licensee will submit a financial plan to LPA that assures coverage of operating costs for care of residents and a plan to maintain adequate financial records by POC date.
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Based on LPA observations, record review, and interviews which were conducted, the licensee did not maintain an adequate financial plan nor were sufficient financial records provided to CCL. Licensee is reported to not be paying his staff. This poses a potential health, safety and personal rights risk to residents 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.
SUPERVISOR'S NAME:Deborah Mullen
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022


LIC809 (FAS) - (06/04)
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