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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880747
Report Date: 11/15/2021
Date Signed: 11/15/2021 03:07:56 PM

Document Has Been Signed on 11/15/2021 03:07 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:CHIHUAHUA HOMEFACILITY NUMBER:
331880747
ADMINISTRATOR:WEST COAST CARE PROVIDERSFACILITY TYPE:
735
ADDRESS:77595 CALLE CHIHUAHUATELEPHONE:
(442) 256-4174
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY: 4CENSUS: 4DATE:
11/15/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Shayla Rodriguez, AdministratorTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced case management visit, as a follow up to an altercation that was made aware of on a previous complaint visit (18-AS-20211029084008). LPA interviewed residents and staff members, and found that on 10/24/21, it was reported on a SIR that Resident (R1) touched Resident (R2). Upon interviews, it was confirmed that R1 went into R2's bedroom, and after speaking with R2, stated that when R1 closed the door it was an invitation to proceed with the action. R1 claims that the action that was taken was done for unknown reasons. Staff immediately reported the incident to LE, after discovering the incident from R1. It was determined that the facility made the appropriate action, but staff failed to report to CCL via fax.

On 10/30/21, LPA interviewed several residents regarding a physical incident that occurred between Resident R3 and Resident R1. Several conflicting accounts to how the incident developed, but all concluded with staff being present and doing their best to circumvent the incident. Both incidents were not reported until 11/5/21. Thus a Type B citation was issued per Title 22 division 6 chapter 1 section 80061(b)(e).
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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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Document Has Been Signed on 11/15/2021 03:07 PM - It Cannot Be Edited


Created By: Jesse Gardner On 11/15/2021 at 02:07 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: CHIHUAHUA HOME
FACILITY NUMBER: 331880747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2021
Section Cited
CCR
80061(b)(e)

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80061 Reporting Requirements:
(b) Upon the occurrence...of any of the events…(1) a report shall be made…to the Licensing Agency next working day...normal business hours. (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.

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Licensee to review regulation, and submit a draft of all employees signatures that the regulation is understood by all staff members by 11/29/21.
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This was not met by: LPA's investigation revealed that the incidents that occurred on 10/24/21 and on 10/30/21 were not sent to CCL until 11/5/21.
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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:Reyna Lacey
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021


LIC809 (FAS) - (06/04)
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