331880722-12-16-2021-18-AS-JGAR-C9S2EE-20211216161950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880722
Report Date: 12/16/2021
Date Signed: 12/16/2021 04:19:57 PM

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 CENTER		FACILITY NUMBER:	331880722
ADMINISTRATOR:	HUDSON, CHANTELLE		FACILITY TYPE:	740
ADDRESS:	25818 COLUMBIA ST		TELEPHONE:	(951) 652-1837
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	58	CENSUS: 35	DATE:	12/16/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Chantelle Hudson, Executive Director		TIME COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to conduct a case management visit in reference to an Unusual Incident Report that the office received on 12-16-21. LPA met with Executive Director Chantelle Hudson, and explained the purpose of the visit, and was granted entry to the facility. There are currently no cases of COVID-19 within the facility.

LPA toured the facility, conducted staff interviews, and interviewed Resident (R1), and Resident (R2). Nothing further is needed at this time.

LPA conducted an exit interview, and a copy of this report was provided to Ms. Hudson.

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 248-0341
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

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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