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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880947
Report Date: 10/19/2022
Date Signed: 10/19/2022 01:23:01 PM

Document Has Been Signed on 10/19/2022 01:23 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:ROY'S DESERT SPRINGS ADULT RESIDENTIAL CAREFACILITY NUMBER:
331880947
ADMINISTRATOR:NTEKIM, JONESFACILITY TYPE:
735
ADDRESS:19531 MCLANE STTELEPHONE:
(760) 778-2083
CITY:NORTH PALM SPRINGSSTATE: CAZIP CODE:
92258
CAPACITY: 92CENSUS: DATE:
10/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Theresa Bader, DirectorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Chinwe Nwogene, arrived unannounced at the facility to conduct a case management visit to address the two #2 separate Special Incident Reports received for two residents engaging in self harm behaviors. LPA met with Director, Theresa Bader and Program Manager, Alexander Ogle who was informed of the purpose of the visit.

The Department received two #2 separate Special Incident Reports (SIR) on 10/18/2022. SIRs given to LPA details, on 10/7/2022, Resident #1 (R1) reported to have swallowed a bottle of Aspirin and was transported to a medical center for further medical evaluation. SIR #2 details Resident #2 (R2) reported feeling suicidal and was found sitting on the floor with superficial cuts on her throat. R2 was transported to medical center for psych evaluation.

LPA Nwogene interviewed staff and resident, and collected pertinent documents.

Based on today’s visit, no information was received by the LPA to indicate there was any lack of care and/or supervision. No citations have been issued at this time. This report was reviewed with and a copy was provided to Theresa Bader.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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