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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880947
Report Date: 03/10/2022
Date Signed: 03/10/2022 12:48:59 PM

Document Has Been Signed on 03/10/2022 12:48 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: 86DATE:
03/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Jones Ntekim, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility unannounced to follow-up on facility staff's criminal background clearance.

During a review of the staff roster, LPA observed Staff One (S1) did not have a Criminal Record Clearance. Mr. Ntekim confirmed staff has been present and working in the facility providing care and supervision to residents since 7/14/2021. Based upon this information, and in compliance with Title 22 regulation, a Type A citation is being issued along with a $500 civil penalty assessment.

In addition, during a visit conducted on 3/8/22, a citation was issued regarding staff (S2) being present in the facility without a criminal record clearance. A civil penalty assessment should have been issued along with the citation; however, it was not. Therefore the $500 assessment is being issued at this time.

An exit interview was conducted and a copy of this report was discussed with and provided to Mr. Ntekim along with copies of the LIC809-D, LIC811, LIC421BG, and Appeal Rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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 03/10/2022 12:48 PM - It Cannot Be Edited


Created By: Jesse Gardner On 03/10/2022 at 12:34 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: ROY'S DESERT SPRINGS ADULT RESIDENTIAL CARE
FACILITY NUMBER: 331880947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2022
Section Cited
CCR
80019(e)(1)

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CRIMINAL RECORD CLEARANCE:(e) All individuals subject to a criminal record..prior to working...(1) Obtain..Licensee did not adhere to the regulation as evidenced by:
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Licensee agreed that S1 will not work until they receive an approved clearance. Licensee will review the regulation and self-certify that they understand by submitting email proof to LPA by 3/11/22.
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Based on LPAs record review, Licensee did not ensure employee had a fingerprint clearance prior to working. This poses an immediate health and safety and 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: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
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