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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880722
Report Date: 10/04/2022
Date Signed: 10/04/2022 02:17:51 PM

Document Has Been Signed on 10/04/2022 02:17 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: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: 43DATE:
10/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
02:30 PM
NARRATIVE
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During Licensing Program Analyst (LPA) Crystal Colvin's investigation of complaint #18-AS-20220926152307, LPA Colvin observed the following violations of Title 22 Regulations which were addressed with Executive Director Shannon Wilkerson:

In review of the Medication Administration Records (MARs) for resident (R1), LPA Colvin observed that there was not a statement or certification from R1's physician stating that either R1 could determine their need for PRN (as needed) medication, whether they could describe their symptoms, or whether they could not do any of these. The facility is required to have this statement for any resident which is prescribed a PRN medication, as the doctor may need to be consulted prior to any administration of medication, depending on the resident's ability to make their needs or symptoms known. Deficiency cited.

Additionally, LPA Colvin observed that the facility was unable to administer R1's medication for Buspirone for over one month due to the facility being out of the medication. Facility staff did not ensure that R1 obtained this medication in a timely manner, which could have been done through taking R1 to an Urgent Care to have the medication re-prescribed while waiting for R1 to see their primary care physician (PCP). R1 resides in this locked facility and therefore in unable to leave to get their own medications refilled and is completely dependent on the facility staff to ensure their medication is available. Deficiency cited.

Based on observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC809D. An exit interview was conducted with Executive Director Shannon Wilkerson where a copy of this report, LIC809D, and appeal rights was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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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Document Has Been Signed on 10/04/2022 02:17 PM - It Cannot Be Edited


Created By: Crystal Colvin On 10/04/2022 at 01:48 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: DESERT HILLS MEMORY CARE CENTER
FACILITY NUMBER: 331880722

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2022
Section Cited
CCR
87465(a)(1)

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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall... provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange...for medical and dental care appropriate to the conditions and needs of residents. This was not met by:
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Licensee agrees to re-evaulate procedure for refill of all residents' medications, and additional steps staff take when barriers to refilling medication are observed. Licensee to provide LPA Colvin with plan for ensuring all residents receive medications in a timely manner, and that medications are refilled
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The Licensee did not comply with the above regulation with at least one resident. LPA Colvin observed that R1 ran out of a medication in early September 2022, and the facility did not ensure the medication was refilled and in the facility until October 2022. This was an immedaite health risk to R1.
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prior to facility running out of medications. Plan due to LPA Colvin by Plan of Correction Date of 10/5/22.
Type B
10/18/2022
Section Cited
CCR87465(b)

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Incidental Medical and Dental Care: (b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.
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Licensee agrees to conduct an internal audit of all residents with PRN medications to ensure that all residents have on file a written statment from their physician in accordance with regulation section cited on their ability to determine need for PRN medication. Licensee may self-certofy once complete.
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The Licensee did not comply with the above regulation with at least one resident (R1). LPA Colvin observed that R1 is prescribed multiple medications and no such statement regarding R1's ability to determine their need was present in file & staff confirmed as well. This is a potential health risk to R1.
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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: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022


LIC809 (FAS) - (06/04)
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