331880692-6-16-2023-18-AS-KBAG-CSUPUK-20230616113741

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880692
Report Date: 06/16/2023
Date Signed: 06/16/2023 11:37:48 AM

Document Has Been Signed on 06/16/2023 11:37 AM - 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SENIOR HOPE MANOR		FACILITY NUMBER:	331880692
ADMINISTRATOR:	DIMAGIBA, ROBERT		FACILITY TYPE:	740
ADDRESS:	74115 PORTOLA POINTE		TELEPHONE:	(760) 610-5011
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92211
CAPACITY:	6	CENSUS: 5	DATE:	06/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Caregiver, Maria Siasat		TIME COMPLETED:	11:40 AM

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	Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that five (5) residents reside at this facility and there are currently (2) staff members present. The facility caregiver (S1), Maria Sisat came to conduct the facility tour. There is an Infection Control Plan on file. Client Records-Incident Reports/Clients Rights-Information/Dental- LPA began review of client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. There were four (4) residents that did not have current or updated physicians’ reports. Personnel Records/Training/and Staffing- LPAs began review of employee records- Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification. The administrator certification is current. Administrator, Robert Dimagiba’s certification expiration date is 06/17/2024. Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen. (Continued on LIC809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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 4

Document Has Been Signed on 06/16/2023 11:37 AM - 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SENIOR HOPE MANOR	FACILITY NUMBER: 331880692
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 4 out of 5 resident's physician's report were not properly maintain, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	S1 states that she will email LPA a confirmation of calling conservators and informing them of needing a physician’s report to be maintain and current.

Type B

Section Cited

CCR

87212(b)(2)(A)

Emergency Disaster Plan

(b) The plan shall be subject to review by the Department and shall include: (2) Plan for evacuation including: (A) Fire safety plan. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in npt maintaining a current fire drill or emergency disaster plan which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	S1 states that she will do perform an emergency and fire drill plan and create a log.

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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SENIOR HOPE MANOR	FACILITY NUMBER: 331880692
	VISIT DATE: 06/16/2023

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
26
27
28
29
30
31
32

(Continuation from LIC809)

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 106.0 degrees F. Laundry facilities and a locked room is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA observed a facility phone, and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home. The fireplace is not operable and secured. There is not a pool at the facility.

Medications- are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. Medications reviewed appear to have been dispensed accurately.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Nine (9) smoke detectors and three (3) carbon monoxide were tested and found to be operational. There were two (2) fire extinguisher charged 08/09/2022. The caregiver stated that the last emergency disaster/ fire drill was done sometime last year but could not recall the exact date and did not have log of the information.

(Continued on LIC809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SENIOR HOPE MANOR	FACILITY NUMBER: 331880692
	VISIT DATE: 06/16/2023

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
26
27
28
29
30
31
32

(Continuation from LIC809)
Based on the information received during this visit today in the areas reviewed, there are two (2) deficiencies observed per Title 22, Division 6 of The California Code of Regulations Article 06. The four (4) resident’s physicians report will be cited under CCR 87458(a). Facility representative S1 states that she will send confirmation of contacting resident’s conservators to schedule an appointment for the physician’s report to be updated. The second deficiency was observed by facility file review and interview, S1 stated that they have not done a fire or emergency drill since last year. S1 stated that the Plan of Correction (POC) for the above deficiencies will be done by 06/23/2023.

This LIC 809 and appeal rights was reviewed with and a copy will be provided to the head caregiver, S1, as evidence by the signature confirmation.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4