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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880947
Report Date: 09/02/2022
Date Signed: 09/02/2022 11:10:34 AM

Document Has Been Signed on 09/02/2022 11:10 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:NTEKIM, JONESFACILITY TYPE:
735
ADDRESS:19531 MCLANE STTELEPHONE:
(760) 778-2083
CITY:NORTH PALM SPRINGSSTATE: CAZIP CODE:
92258
CAPACITY: 92CENSUS: 91DATE:
09/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Jones NtekimTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to the facility to follow up on information obtained during the investigation of the death of Resident 1 (R1). LPA met with Administrator Jones Ntekim.

During the Department’s investigation of R1’s death, it was discovered that staff failed to perform hourly check’s on R1 during the afternoon of February 15, 2022. Facility Room Check logs obtained by the Department revealed facility staff did not perform room checks on R1 at 2:00pm, 4:00pm, 5:00pm, 6:00pm and 7:00pm. In addition, facility video footage show staff conducted a room check at 5:05pm but did not return until 7:22pm. Per interviews with staff, resident room checks are to be completed every hour and are to be documented on the Facility Room Check logs.


Based upon the above stated information it was determined that facility staff failed to provide the care and supervision necessary to meet the resident’s needs. In accordance with Title 22 regulations a citation is being issued as detailed on the LIC809D.


An exit interview was conducted and a copy of this report, along with Appeal Rights was reviewed with and provided to Administrator Jones Ntekim.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2022
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 09/02/2022 11:10 AM - It Cannot Be Edited


Created By: Jesse Gardner On 09/02/2022 at 10:52 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: 09/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2022
Section Cited
CCR
80065(a)

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Responsibility for providing care and supervision – The Licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not being met as evidenced by:
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Licensee states that training will be conducted for all staff regarding the appropriate supervision of clients and submit proof of completion to LPA by POC date.
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Staff interviews and a review of facility documentation revealed staff did not perform a room check for R1 on February 15, 2022 at 2:00pm; 4:00pm; 5:00pm; 6:00pm and 7:00pm. This posed an immediate health, safety and personal rights violation 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: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022


LIC809 (FAS) - (06/04)
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