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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880678
Report Date: 05/24/2022
Date Signed: 05/24/2022 02:18:26 PM

Document Has Been Signed on 05/24/2022 02:18 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:SUN CITY VILLAFACILITY NUMBER:
331880678
ADMINISTRATOR:CLARK-TAYLOR,ZINICAFACILITY TYPE:
740
ADDRESS:78950 MIMOSA DRTELEPHONE:
(951) 688-6186
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY: 6CENSUS: 3DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Anahi Torres - CaregiverTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with caregiver Anahi Torres and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with caregiver Anahi Torres, who LPA Colvin found to be successfully incorporating the several aspects of the facility's Mitigation Plan. Residents have hand sanitizer available to them, and all resident bathrooms were stocked with hand soap. LPA Colvin observed the resident bathrooms to not have any paper towels. LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note during today's inspection. LPA Colvin inquired about the lack of paper towels and confirmed with caregiver Anahi Torres that residents use hand towels that are stored in the bathroom instead of paper towels. LPA Colvin observed the cloth towels in each of the two resident bathrooms. Title 22 Regulations prohibit the use of common towels. Deficiency cited.

While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns), which was located in the front of the facility where guests are screened, as well as in the resident bedrooms (gloves). LPA Colvin observed the facility to have a minimal amount of PPE (enough for one week) and no N95 masks. LPA Colvin will be issuing a Techincal Advisory Note for the facility having under the recommended amount of 30 days of PPE. LPA Colvin went over the various recommended training for facility staff with caregiver Anahi Torres in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. LPA Colvin inquired as to if staff have been fit tested for N95 masks, and caregiver Anahi Torres informed LPA Colvin that staff have not been fit tested for N95 masks. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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: SUN CITY VILLA
FACILITY NUMBER: 331880678
VISIT DATE: 05/24/2022
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LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. LPA Colvin will be providing Anahi with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

Prior to LPA Colvin entering the facility, LPA Colvin observed a sign on the front door of the facility stating that masks are optional for persons who are vaccianted. Additionally, LPA Colvin observed caregiver Anahi Torres to not be wearing any type of face covering. At this time, face coverings are still required in all residential facilities, as per the latest guidance from Community Care Licensing (CCL) in Provider Information Notice (PIN) 22-15-ASC. LPA Colvin will be issuing a TA Advisory Note for staff to not be wearing a face covering. LPA Colvin also instructed staff to remove the sign on the front door regarding vaccinated persons not needing to wear masks. LPA Colvin observed a sign-in sheet at the front door of the facility, and confirmed that visitors and staff are being screened prior to entering the facility.

An exit interview was conducted with caregiver Anahi Torres and a copy of this report, LIC809, LIC9102 TA Advisory Notes, and appeal rights were provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2022 02:18 PM - It Cannot Be Edited


Created By: Crystal Colvin On 05/24/2022 at 01:56 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: SUN CITY VILLA
FACILITY NUMBER: 331880678

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services: (a) Living accommodations and grounds shall be related to the facility's function...The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident...the licensee shall assure provision of: (C) Clean linen...The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 resident bathrooms which poses a potential health risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Licensee to remove cloth towels from the resident bathrooms and instead provide paper towels for resident use. Alternatively, Licensee may have residents use cloth towels so long as residents store cloth towels in their own rooms to ensure no other resident uses them. Licensee to self-certify to LPA Colvin which option they are implementing in the facility. Plan of Correction due date is 5/27/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022


LIC809 (FAS) - (06/04)
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