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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880655
Report Date: 02/09/2024
Date Signed: 02/09/2024 04:59:42 PM


Document Has Been Signed on 02/09/2024 04:59 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 2FACILITY NUMBER:
331880655
ADMINISTRATOR:FRANCESCA MORALESFACILITY TYPE:
740
ADDRESS:670 HIGHLAND DRTELEPHONE:
(760) 507-8140
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92264
CAPACITY:6CENSUS: 5DATE:
02/09/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Staff, Nestor VidalTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct a Plan of Correction (POC) visit. LPA met with Staff, Nestor Vidal. LPA called Licensee Arden over the phone during the time of the visit. LPA was unable to contact the administrator, Francesca Morales. At the time of the visit LPA conducted a walk through and reviewed staff clearances.

The following POC's were corrected at the time of the visit:
During Annual visit conducted on 1/30/2024, CCR Title 22 Section 87555(b)(8) General Food Service Requirements was cited and POC to clear out pantry and maintain a 7-day supply of non-perishable foods and send proof of this to the LPA by 1/31/2024. LPA checked the pantry and non-perishables and found that they all had current dates. Therefore, the deficiency is cleared but is late. The facility will be issued civil penalties for failure to correct in the amount of $100 per day for (10) days. The Deficiency was cleared at the time of the visit and a clearance letter was provided to Licensee.

The following POC's were not corrected at the time of the visit:
During Annual visit conducted on 1/30/2024, California Code of Regulations (CCR) Title 22 Section 87411(f) Personnel requirements- General was cited and POC was to send LPA proof of a completed and signed physical for the administrator. This was due by 1/31/2024. At this time, the LPA has not received any proof for this citation. During the time of the visit LPA spoke with Administrator was unable to be contacted at the time of the visit as they did not answer their phone. Therefore, civil penalties are being assessed for (10) days in the amount of $100 per day.

During Annual visit conducted on 1/30/2024, CCR Title 22 Section 87705(l)(6) was cited and POC was to retrain staff on ways to mitigate dementia residents from wandering and the potential hazards of placing a padlock on an egress point. This was due by the POC due date 2/5/2024. As of this date, the department has not received the plan of correction. This is a repeated violation of the same regulation which will result in immediate civil penalty of $250.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
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 3


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: ASSURANCE HOME 2
FACILITY NUMBER: 331880655
VISIT DATE: 02/09/2024
NARRATIVE
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During Annual visit conducted on 1/30/2024, Health and Safety Code Section 1569.605 was cited and POC was to provide proof of liability insurance denial, and provide a written statement that the licensee would actively seek a new company to be insured with. This was due by the POC due date 1/31/2024. As of this date, the department has not received the plan of correction. Therefore, the facility will be issued civil penalties for failure to correct in the amount of $100 per day for (10) days.

During Annual visit conducted on 1/30/2024, CCR Title 22 Section 87633(b) Hospice Care for Terminally Ill Residents was cited and POC was to maintain a current plan of care for resident on hospice and send the plan of care to LPA by 2/2/2024. As of this date, the department has not received the plan of correction. Therefore, the facility will be issued civil penalties for failure to correct in the amount of $100 per day for (8) days.

During the visit, LPA rang door bell and knocked on the door for 10 minutes and received no answer. LPA called the home phone and the administrator and received no answer. LPA walked to the back of the home and found the pool door open and knocked on staff room door. LPA was informed that only staff at facility was sleeping in their room. This will result in an immediate civil penalty of $1000 and deficiency as this is a repeated violation. Immediate civil penalty for unlocked pool gate and deficiency was cited. Plan of correction was created with licensee over the phone.

An exit interview was conducted where this report was reviewed with Staff, Nestor Vidal Licensee was informed that civil penalties will continue to accrue until the corrections are received. LIC421FC were reviewed and provided to Staff, Nestor Vidal.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/09/2024 04:59 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: ASSURANCE HOME 2
FACILITY NUMBER: 331880655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2024
Section Cited
CCR
87468.2(a)(4)

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(a) In addition to the rights...(4) To care, supervision...that meet their individual needs and are delivered by staff that are sufficient in numbers...
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The licensee agreed to call another staff on duty for night shift to ensure supervision of residents at all times. The licensee stated they would provide a written statment certifying they will have sufficent staffing by POC due date.
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Thsi requirment was not met as evidenced by: Based on interview and observation, LPA found (1) caregiver at the home who self admitted to sleeping with residents in care. This poses an immediate health saftey or personal rights risk.
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Type A
02/10/2024
Section Cited
CCR87307(e)

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(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility...swimming pools...when not in active use...
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The staff secured the gate during the time of the visit. The licensee agreed to speak with staff on ensure the gate is locked at all times. Written notification of completion will be sent to the LPA by POC due date.
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This requirment was not met as evidenced by: based on observation and interview, the pool door was left open while staff self admitted to sleeping with residents in care. This poses an immediate health, saftey or personal rights risk.
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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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
LIC809 (FAS) - (06/04)
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