331880734-9-25-2023-18-AS-KBAG-CVZU26-20230925151125

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880734
Report Date: 09/25/2023
Date Signed: 09/25/2023 03:11:30 PM

Document Has Been Signed on 09/25/2023 03:11 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	RANCHO MIRAGE TERRACE		FACILITY NUMBER:	331880734
ADMINISTRATOR:	MONIQUE MOREIRA		FACILITY TYPE:	740
ADDRESS:	34560 BOB HOPE DRIVE		TELEPHONE:	(760) 770-7737
CITY:	RANCHO MIRAGE	STATE: CA	ZIP CODE:	92270
CAPACITY:	142	CENSUS: 125	DATE:	09/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Administrator, Monique Moreira		TIME COMPLETED:	03:30 PM

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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 one-hundred twenty-five (125) residents live at this facility. There are twenty-six (26) staff members present. The Administrator, Monique Moreira conducted the tour. The Business Director, Sandra Zendejas completed the tour.

Client Records/Incident Reports/Clients Rights Information: LPA reviewed 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.

Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Five (5) record 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 administrative organization.

(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: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RANCHO MIRAGE TERRACE	FACILITY NUMBER: 331880734
	VISIT DATE: 09/25/2023

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(Continuation from LIC809)

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.

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 facility is maintained at 78 degrees for the resident’s comfort. Lighting is sufficient for safety. Water temperature measured at 108.0 degrees F. Laundry is done in the designated laundry room on the first floor. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There is not a fireplace at this facility. There is a gated pool at the facility, that is surrounded by a 5-foot gate and latch. The facility had their last annual fire inspection by Fire Master on 11/16/2022. LPA reviewed the facility’s last disaster drills, which met the department's requirements.

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements.

(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: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RANCHO MIRAGE TERRACE	FACILITY NUMBER: 331880734
	VISIT DATE: 09/25/2023

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(Continuation from LIC809)

Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked pushcart allocated for medication storage in the Medication Room. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed if they were dispensed accurately.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The fire extinguishers throughout the facility were last serviced and tagged on 11/22/22. According to the fire inspection, there are nineteen (19) fire extinguishers throughout the facility.

Pursuant to the Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to the Business Manager, Sandra Zendejas.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC809 (FAS) - (06/04)

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