331880678-5-28-2026-18-AS-TNWA-DUHUAE-20260528152438

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880678
Report Date: 05/28/2026
Date Signed: 05/28/2026 03:27:28 PM

Document Has Been Signed on 05/28/2026 03:27 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:	SUN CITY VILLA		FACILITY NUMBER:	331880678
ADMINISTRATOR/ DIRECTOR:	CLARK-TAYLOR,ZINICA		FACILITY TYPE:	740
ADDRESS:	78950 MIMOSA DR		TELEPHONE:	(951) 688-6186
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92211
CAPACITY: 6		CENSUS: 4	DATE:	05/28/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:50 AM
MET WITH:	Anika Bus Caregiver		TIME VISIT/ INSPECTION COMPLETED:	03:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/28/2026 at 10:50 am, Licensing Program Analyst (LPA) Toni Nwala made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Facility Caregiver, Anika Bus who was informed of the purpose of the visit. Licensee also arrived to the facility shortly after arrival. LPA did observe an individuals on the premises at time of visit whom was not associated to the facility. Citations will be issued. LPA toured the facility with facility Caregiver, Anika Bus and observed the facility is made up of a one story home with five (5) bedrooms, two (2) bathrooms, a kitchen, dining area, living room, laundry room, and attached garage. Resident bedrooms had the required bedding, furniture, and lighting. Bathrooms had grab bars and non-skid mats in the showers. No bodies of water were observed on the premises. Indoor and outdoor pathways were free of obstruction. The facility had a two day supply of perishable foods and seven day supply of non-perishable foods. Medications and cleaning solutions/disinfectants are separately stored in different cabinets in the locked laundry room. Continue on 809-C .

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Toni Nwala
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SUN CITY VILLA	FACILITY NUMBER: 331880678
	VISIT DATE: 05/28/2026

NARRATIVE

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LPA toured the garage and observed an additional food and emergency water. The facility has a room with additional incontinent supplies, blankets, linens, and pillows and emergency food. Licensee tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed a fire extinguisher mounted near the kitchen last serviced on 05/11/2025. Staff present has a criminal record clearance and a valid first aid/CPR certification. Resident files reviewed had updated physician's reports and personal rights. LPA reviewed the facility's Emergency Drill Participation Time sheet noting the facility's last fire drill was conducted on 3/5/2026 LPA checked water temperature and reading is 109.7F. Long Term Care Ombudsman's contact information, complaint procedures, and facility sketch are visibly posted in a hallway.

An exit interview was conducted, and Appeal Rights were discussed with Licensee. Report was provided to Licensee. Please see LIC 809D for citations related to the deficiencies observed during inspection

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Toni Nwala
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/28/2026 03:27 PM - It Cannot Be Edited

Created By: Toni Nwala On 05/28/2026 at 02:32 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: 05/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on obervation and record review, the licensee did not comply with the section cited above in 4 out of 4 residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/29/2026
	Plan of Correction
1 2 3 4	Licensee agreed to associate volunteer to facility.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:

	Toni Nwala
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

LIC809 (FAS) - (06/04)

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