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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880655
Report Date: 03/30/2022
Date Signed: 03/30/2022 05:06:21 PM


Document Has Been Signed on 03/30/2022 05:06 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 2FACILITY NUMBER:
331880655
ADMINISTRATOR:ARDEN ZALSOSFACILITY TYPE:
740
ADDRESS:670 HIGHLAND DRTELEPHONE:
(818) 482-4256
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92264
CAPACITY:6CENSUS: 4DATE:
03/30/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Licensee Arden ZalsosTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unanounced in order to follow up on the Plan of Corrections for deficiencies cited during the facility's Annual Inspection on 3/15/22. LPA identified herself and discussed the purpose of the visit with Licensee Arden Zalsos. Below is a summary of what was observed:
  • Deficiency 87465(h)(2) for Centrally Stored Medication: During today's inspection, LPA Colvin observed that medication continues to be stored in an unlocked and accessible location for residents. LPA Colvin observed that refrigerated medications are kept in a refrigerator in the staff room, which was not locked during LPA Colvin's inspection, and was accessible without staff or keys. Additionally, LPA Colvin conferred with LPA Jesse Gardner, who cited the deficiency on 3/15/22, and confirmed that none of the items requested to be submitted for the Plan of Correction have been received. Therefore, since the Licensee has not corrected the deficiency by the Plan of Correction date of 3/22/22, LPA Colvin will be issuing civil penalties in the amount of $100 per day since the due date. Civil penalties are being issued in the amount of $800 ($100 per day x 8 days, 3/23/22 - 3/30/22, = $800).

  • Deficiency 87468.1(a)(2) for Unclean Bathroom: LPA Colvin toured the facility and observed that the resident bathroom was unclean with dark marks on the floor, possibly dirt or feces, that appeared to be foot prints or from objects being moved around on the floor. LPA Colvin observed that the Licensee additionally has not submitted a cleaning schedule, per the Plan of Corrections to ensure the bathroom and other areas of the facility are kept clean. Licensee states that cleaning schedule was created, but has not been submitted as he thought the due date was later. Licensee unable to provide or show LPA Colvin the cleaning schedule during this visit, as it is on his iPad, which is not with him currently. , LPA Colvin will be issuing civil penalties in the amount of $100 per day since the due date. Civil penalties are being issued in the amount of $800 ($100 per day x 8 days, 3/23/22 - 3/30/22, = $800).
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ASSURANCE HOME 2
FACILITY NUMBER: 331880655
VISIT DATE: 03/30/2022
NARRATIVE
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Additionally, during today's inspection, the following deficiencies were cited:
  • Failure to Pay Licensing Fees: LPA Colvin observed that the Licensee currently owes $1,484.00 for unpaid annual fees for 2020 & 2021, as well as subsequent late fees. Deficiency cited.

  • Failure to Maintain Current Liability Insurance: Licensee does not have proof of liability insurance, and Licensing has reason to believe that the facility no longer has liability insurance. Deficiency cited.


  • Failure to Provide Licensing Access to Staff Files: LPA Colvin requested to view staff files to confirm that they have been fingerprinted, but files are not maintained on site and were not available for LPA Colvin to review. Deficiency cited.

  • Failure to Provide Licensing Access to Resident Files: LPA Colvin requested to see resident files, but was only able to review two of four resident files, as the other two files are digital, and the Licensee was unable to provide LPA Colvin with access to the files at this time. Deficiency cited. This is a repeated deficiency that was cited on 9/22/21, and therefore warrants a civil penalty in the amount of $250.

  • Administrator Not Present Sufficient Hours at Facility: LPA Colvin learned through interview with Administrator/Licensee Arden that he works a full time job as well as is Administrator over another facility (Assurance Home #1, license #331880654). Arden additionally stated that he is present at this location approximately 6 to 7 hours a week. This is not sufficient to ensure proper oversight of the facility. Deficiency cited.

  • Alarms Not Present on Exits: LPA Colvin observed that there are no auditory alarms on the exit doors of the facility. The facility retains Dementia residents, and is therefore required to have alarms on the doors to alert staff of resident(s) potential exit from the facility. Deficiency cited.

  • Lack of Awake Staff at Night: The facility does not have awake staff during the night, but retains a resident who has Dementia (R1) and wanders. Deficiency cited.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 03/30/2022 05:06 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
CCLD Regional Office, 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: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2022
Section Cited

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Criminal Record Clearance: (e) All individuals... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement was not met as evidenced by:
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Based on record review and interviews, the Licensee did not comply with the above regulation with two staff (S1 & S2). LPA Colvin observed that S2 is not fingerprinted, and S1 has not obtained background clearance from Department of Justice yet. This is an immediate health and safety risk to residents.
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Type A
04/01/2022
Section Cited

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Licensing Fees: (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This requirement was not met as evidenced by:
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Based on record review, the Licensee has not complied with the above regulation with annual fees assessed 2020 & 2021, and late fees. LPA Colvin observed that the Licensee has not paid the annual fees and has accured a late charge. This is an immediate safety risk to residents in care, as license can be revoked.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/30/2022 05:06 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
CCLD Regional Office, 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: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/13/2022
Section Cited

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Personnel Records: (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours... This requirement was not met as evidenced by:
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Based on interviews, the Licensee did not comply with the above regulation with two staff files (S1 & S2). LPA Colvin was unable to review staff files as Licensee does not have physical copies and could not access digital files during inspection. This is a potential safety risk to all residents in care.
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Type B
04/13/2022
Section Cited

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Liability insurance; coverage requirements: On and after July 1, 2015, all residential care facilities for the elderly...shall maintain liability insurance covering injury to residents and guests...caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement was not met
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Based on record review, the Licensee did not comply with the above regulation. LPA Colvin was informed that the facility does not have current liability insurance sufficienct to the requirements. Licensee was unable to provide proof of coverage during inspection. This is a potential personal rights violation.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
LIC809 (FAS) - (06/04)
Page: 4 of 8


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 2
FACILITY NUMBER: 331880655
VISIT DATE: 03/30/2022
NARRATIVE
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  • Dementia Resident Lacking Updated Physician's Report: LPA Colvin observed that R1's Physician's Report marks R1 as having Dementia. Additionally, this Physician's Report is dated March of 2020. There are no other updated Physician's Reports available for LPA Colvin to inspect in R1's file. Deficiency cited.

  • Staff Present in the Facility Without Background Clearance: LPA Colvin observed that two staff members were present during today's inspection (S1 & S2), neither of which had cleared criminal background clearance from FBI. LPA Colvin observed that while S1 had been fingerprinted and was associated to the facility, they have not yet been cleared by FBI. S1 has reportedly been working in the facility for 6 months, and lately has been working 7 days a week. Additionally, S2 has not been fingerprinted, and has been present in the facility training since 3/28/22. Since the facility has already been cited in the last 12 months for having staff who are not fingerprint cleared present in the facility, the maximum amount of civil penalties that can be assessed (per staff member) is $100 per day for 30 days each. LPA Colvin is issuing civil penalties in the amount of $3,000 for S1, as S1 has been working at the facility for 6 months ($100 x 30 days), and $300 for S2, as S2 has only been at the facility since Monday, 3/28/22 ($100 x 3 days). Total amount assessed for this deficiency is $3,300.

Community Care Licensing Regional Manager Reyna Lacey & Licensing Program Manager Jazmond Harris informed LPA Colvin that S1 would be permitted to stay due to having Department of Justice (DOJ ) clearance, and no other staff being available to relieve S1. LPM Harris additionally informed LPA Colvin and Licensee (via telephone) that while Licensing and the Licensee look into the status and potential issues with S1's fingerprints, Licensing will not continue to cite civil penalties for S1's presence at the facility. S2 was removed during LPA Colvin's inspection.

Total amount of civil penalties assessed is $5,150. Civil penalties for the prior deficiencies not corrected will continue to accrue at $100 per day, per deficiency until corrections are made.

An exit interview was conducted with Licensee Arden Zalsos, and a copy of this report, LIC 809D, LIC421BG, and appeal rights was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 03/30/2022 05:06 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
CCLD Regional Office, 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: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/13/2022
Section Cited

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Resident Records: (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.... This requirement was not met as evidenced by:
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Based on observations and interview, Licensee did not comply with the above regulation with two resident files (S3 & S4). LPA Colvin observed that only 2 of 4 resident files were available for LPA Colvin to review. This is a potential health risk for R3 & R4.
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Type B
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Section Cited

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Administrator - Qualifications and Duties: (a) All facilities shall have a qualified and currently certified administrator...The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours... This requirement was not met as evidenced by:
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Based on interviews, the Licensee did not comply with the above regulation. LPA Colvin learned that the Administrator is not at the facility enough hours per week to ensure proper oversight of the facility. This is a potential health risk to all 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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 03/30/2022 05:06 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
CCLD Regional Office, 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: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/01/2022
Section Cited

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Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by:
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Based on observation, the Licensee did not comply with the above regulation with at least one exit door. LPA Colvin observed the front door to the facility to not have an alarm, and R1 exited from the door during LPA Colvin's inspection. R1 has Dementia. This is an immediate safety risk for R1.
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Type B
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Section Cited

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Care of Persons with Dementia: (c) Licensees ...shall be responsible for ensuring...: (4) There is an adequate number of direct care staff...as identified in his/her current appraisal. (A) ...a facility with fewer than 16 residents shall have at least one night staff person awake and on duty... This requirement was not met by:
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Based on record review and interview, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin observed that R1 has Dementia and their Physician's Report states that they wander. Licensee does not have awake staff at night. This is a potential safety risk to R1.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
LIC809 (FAS) - (06/04)
Page: 7 of 8


Document Has Been Signed on 03/30/2022 05:06 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
CCLD Regional Office, 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: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/13/2022
Section Cited

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Care of Persons with Dementia: (c) Licensees...shall be responsible for ensuring...:(5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually... This requirement was not met as evidenced by:
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Based on record review, the Licensee did not comply with the above regulation with at least one resident (R1). LPA Colvin observed that R1 has Dementia, but the most recent Physician's Report in their file is from 2020. This is a potential health and safety risk to R1.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
LIC809 (FAS) - (06/04)
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