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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880678
Report Date: 05/17/2024
Date Signed: 05/17/2024 03:02:00 PM

Document Has Been Signed on 05/17/2024 03:02 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 VILLAFACILITY NUMBER:
331880678
ADMINISTRATOR/
DIRECTOR:		CLARK-TAYLOR,ZINICAFACILITY TYPE:
740
ADDRESS:78950 MIMOSA DRTELEPHONE:
(951) 688-6186
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY: 6CENSUS: 3DATE:
05/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Zinica Clark-Taylor, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted a required annual inspection to the facility. The LPA was allowed entrance into the facility and met with Licensee, Cinica Clark-Taylor and Caregiver Manager, Ionut Stan. The LPA informed the Licensee and Caregiver Manager of the purpose for the visit. The facility currently has an approved Hospice Waiver for four (4) residents. The inspection included the following:

Physical Plant: The facility consists of four (4) resident bedrooms, one staff room, a dinning area, a living space, an open kitchen, a garage space with laundry, and a patio with sufficient seating and space for activities. There are no bodies of water located on the property. According to the Licensee, no weapons are stored in the home. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats or strips present. The carbon monoxide/smoke detector was tested by the Administrator and was observed to be in operating condition. The home was kept clean and free of any odors.

Food Service: There is a minimum of two (2) days supply of perishable foods and one (1) week's supply of non-perishable foods available.

Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. Staff responsible for direct care and supervision have current first aid and CPR training. Required training such was Dementia Care training, medication training, postural support training, restricted health care training, and hospice care training were not observed to be completed. Citations will be issued. The facility was not operating beyond the conditions specified on the license. The LPA was informed by the Administrator there are currently no residents in care who are
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SUN CITY VILLA
FACILITY NUMBER: 331880678
VISIT DATE: 05/17/2024
NARRATIVE
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receiving hospice services. There is an Emergency and Disaster Plan observed on file. Proof of emergency drills was observed on file. All services requiring specialized skill are being performed by personnel qualified as appropriately skilled professionals. Full length bed rails were observed to be utilized for Resident Three (R3). The resident is not receiving hospice services. No documentation of a request by the facility to utilize the rails could be provided. A citation will be issued.

Medication Review: The LPA reviewed medications for two residents. Medications were observed to be separate and inaccessible to unauthorized individuals.

An exit interview was conducted with the Licensee and Caregiver Manager; this report was reviewed and a copy was provided, along with the LIC 811 and instructions on appeal rights.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/17/2024 03:02 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 05/17/2024 at 02:14 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: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of one staff members who did not have the required training. Proof of 20 hours of annual training could not be provided for S3. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/17/2024
Plan of Correction
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The Licensee stated she would provide proof of training for S3 by the POC due date.
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of one staff members who did not have the required training on file. Proof of annual medication training was not observed on file for S3. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/17/2024
Plan of Correction
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Administrator stated he would provide proof of training for S3 by the POC due date.
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 Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/17/2024 03:02 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 05/17/2024 at 02:18 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: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
POSTURAL SUPPORTS: (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 one out of one residents who had full length bed rails. This poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 05/18/2024
Plan of Correction
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The Administrator stated he would provide the LPA with an exception request to utilize the bed rails.
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024


LIC809 (FAS) - (06/04)
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