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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880947
Report Date: 03/08/2022
Date Signed: 09/02/2022 10:38:29 AM

Document Has Been Signed on 09/02/2022 10:38 AM - 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: 86DATE:
03/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jones Ntekim, AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Jesse Gardner arrived at the facility to follow up an information reported to the Department regarding a personal relationship between Staff 1 (S1) and Resident 1(R1). LPA met with Administrator Jones Ntekim.

The Department became aware of a personal relationship between S1 and R1 while investigating the death of R1. The information reported is being investigated under complaint control # 18-AS-20220224091908.

Nothing further is needed at this time and no deficiencies are being cited. An exit interview was conducted and a copy of this report and a hand-typed LIC811 was provided to Administrator Jones Ntekim.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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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Document Has Been Signed on 03/08/2022 12:14 PM - It Cannot Be Edited


Created By: Jesse Gardner On 03/08/2022 at 11:47 AM
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: ROY'S DESERT SPRINGS ADULT RESIDENTIAL CARE
FACILITY NUMBER: 331880947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2022
Section Cited
CCR
80072

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PERSONAL RIGHTS:
(a)..each client shall have personal rights which include..(1)To be accorded dignity..This was not met by Licensee as evidenced by:
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Licensee terminated mentioned employee, and agrees to conduct mandatory ethics/boundaries training for all staff on 3/10/22. Licensee will submit sign-in/roster upon completion by 3/22/22.
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Based on LPAs interviews, Licensee did not ensure R1 was free from staff engaging unethically. This poses a potential health, safety, or personal rights risk to residents in care.
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022


LIC809 (FAS) - (06/04)
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