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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880654
Report Date: 12/07/2023
Date Signed: 12/07/2023 02:50:13 PM


Document Has Been Signed on 12/07/2023 02:50 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:ASSURANCE HOME 1FACILITY NUMBER:
331880654
ADMINISTRATOR:FRANCESCA MORALESFACILITY TYPE:
740
ADDRESS:627 HIGHLAND DRTELEPHONE:
(760) 537-1969
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92264
CAPACITY:9CENSUS: 0DATE:
12/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Segundina "Connie" EdwardsTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit for the purpose of the facility's closure. LPA made a telephone call to Licensee Arden Zalsos who was informed of the purpose of the visit. LPA met with Resident Segundina Edwards and toured the home. Edwards indicated that 10 residents including herself are currently residing in the home. Only 2 of 10 residents were present including Segundina and her partner. Edwards stated that no care is being provided, and that each resident is independent. LPA did not observe hospital beds, centrally stored medication, or records being kept for anyone who resided in the home.

On 2/15/2023, Licensee Francesca Morales emailed LPA Jesse Gardner stating a written 60 day notice had been served to the residents and their responsible parties of the intended eviction due to the facility's closure. Licensee Morales provided copies of the notices.

On 12/07/2023, LPA contacted Licensee Arden Zalsos who indicated that the facility was closed as of 4/1/2023, and all residents, Resident One (R1), Resident Two (R2), Resident Three (R3), Resident Four (R4), and Resident Five (R5) had been relocated.

On today's date, LPA inspected the facility, which included the bedrooms, bathrooms, dining area, kitchen and outdoor areas. LPA requested Licensee Zalsos submit their original license to CCLD. The facility will be closed on this date 12/7/23.

An exit interview was conducted where this report was reviewed and provided to Edwards.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
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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