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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880722
Report Date: 02/08/2024
Date Signed: 02/08/2024 03:12:32 PM


Document Has Been Signed on 02/08/2024 03:12 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:DESERT HILLS MEMORY CARE CENTERFACILITY NUMBER:
331880722
ADMINISTRATOR:HUDSON, CHANTELLEFACILITY TYPE:
740
ADDRESS:25818 COLUMBIA STTELEPHONE:
(951) 652-1837
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:58CENSUS: 33DATE:
02/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shannon Moore Wilkerson, AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility for a complaint investigation. The LPA met with Shannon Moore Wilkerson, Administrator, and informed her of the purpose for her visit. During the visit, the LPA observed the following violation.

Staff One (S1), who is listed on the facility's Personnel Report, does not have a California criminal record clearance. Staff interviews revealed S1 is an employee of the facility and does have occasional contact with residents in care. According to Administrator Wilkerson, S1 has been working in the facility since 2022. This violation poses an immediate threat to the health and safety of the residents in care. A citation and civil penalty will be issued.

An exit interview was conducted with Administrator Wilkerson; this report was reviewed and a copy was provided, along with the LIC 811 and instructions on appeal rights.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
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 2


Document Has Been Signed on 02/08/2024 03:12 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: DESERT HILLS MEMORY CARE CENTER
FACILITY NUMBER: 331880722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/09/2024
Section Cited
CCR
87355(e)(1)

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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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or
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Administrator Wilkerson stated she will audit the facility's personnel roster monthly to ensure all staff are fingerprint cleared.
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This requirement was not met, as evidenced by: Based on records review and interviews, S1 does not have a California criminal record clearance. This violation poses an immediate threat to the 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: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2