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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880947
Report Date: 02/16/2022
Date Signed: 02/16/2022 03:33:59 PM

Document Has Been Signed on 02/16/2022 03:33 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:ARNETT, KIMBERLYFACILITY TYPE:
735
ADDRESS:19531 MCLANE STTELEPHONE:
(760) 778-2083
CITY:NORTH PALM SPRINGSSTATE: CAZIP CODE:
92258
CAPACITY: 92CENSUS: 85DATE:
02/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Jones Ntekim, AdministratorTIME COMPLETED:
03:50 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 2/16/22 at 1:45pm, Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to follow-up on the death of an Resident One (R1). LPA made contact with Administrator Jones Ntekim and advised the reason for the visit. Mr. Ntekim allowed facility access.

Community Care Licensing Division (CCLD) received an unusual incident report from the facility on 2/16/21 to report the death of the resident. The following is a brief description of the visit:

LPA interviewed Mr. Ntekim regarding the circumstances of the residents death. LPA collected pertinent resident file information, relevant responsible party contact information, as well as staff and consumer roster information.

Mr. Ntekim was advised that additional information including, interviews, calls, and record review may be needed to complete CCLD's investigation at a later date.

An exit interview was conducted with Mr. Ntekim, and a copy of this report was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2022
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