<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880947
Report Date: 06/30/2023
Date Signed: 06/30/2023 03:04:26 PM

Document Has Been Signed on 06/30/2023 03:04 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 ASC, 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: 91DATE:
06/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Alexander Ogle, AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 6/30/2023, Licensing Program Analyst (LPA), Chinwe Nwogene, conducted an unannounced visit at the facility to conduct a case management visit to address an incident involving a death of Client One (C1). LPA met with Administrator, Alexander Ogle who was informed of the purpose of the visit.

The Department received a death report from the facility on 6/30/2023 regarding a client's death on 6/29/2023 at 7.20pm. Administrator, Alexander Ogle stated subsequent death report has not been received yet. During the visit LPA interviewed staff and reviewed resident file and obtained copies of the documents listed below.
  • ID and Emergency Information
  • Admission Agreement
  • Medical Orders – from 4/2022
  • Resident Pre-appraisal: Olga stated no recent appraisal was conducted
  • Quarterly Progress Notes
  • Medication Records
  • Personal Property Record
  • Physician Report
  • Incident reports leading up to the death
  • Resident Roster

Administrator, Alexander Ogle stated facility will notify Licensing when the real cause of death is known. No information received today indicates any lack of care and/or supervision.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed with and provided to Alexander Ogle.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1