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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880965
Report Date: 03/02/2021
Date Signed: 03/04/2021 08:06:02 AM

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:CULTURAL MANOR SENIOR LIVINGFACILITY NUMBER:
331880965
ADMINISTRATOR:PIERCE, JEFFREY R.FACILITY TYPE:
740
ADDRESS:390 W CORTEZ ROADTELEPHONE:
(310) 691-3498
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:6CENSUS: 0DATE:
03/02/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jeffrey PierceTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Stephanie Williams conducted a pre-licensing inspection via video-conferencing application due to the COVID-19 pandemic. LPA identified herself and conducted the tele-visit with Administrator, Jeffrey Pierce.

The pending application is for a Residential Care Facility for the Elderly. The facility has been granted a fire clearance for 6 non-ambulatory residents by the Palm Springs Fire Department on 8/24/2020. The facility has a total of 5 resident bedrooms, 4.5 bathrooms, a kitchen/dining area, a living room, family room, and attached garage. LPA toured the interior and exterior area of the facility. The following was observed, reviewed, and inspected:

LPA inspected resident bedrooms; the bedrooms had the required bedding, furniture, and storage space. LPA inspected resident bathrooms; bathroom appliances were operating in safe and sanitary conditions and were equipped with non-skid mats and grab bars. LPA inspected the kitchen; knives, cleaning supplies, and toxins were locked and inaccessible to residents. Dishes, glasses, and utensils were in good condition and stored in a safe manner. LPA inspected the common areas; LPA observed required postings including the department's complaint poster, residents personal rights, and the facility's emergency/disaster plan. The facility was equipped with a complete first aid kit as well as the first aid manual. There was a locked and centralized storage area for medications. The facility had a designated area for client files and staff files. There was adequate seating in the common areas. LPA also observed activities for the residents; such as, board games and artwork activities. LPA inspected the outdoor space; there is a pool on the property; however, the pool was locked and inaccessible at the time of inspection. The outdoor area also had a shaded seating area for residents. LPA observed that at least one side gate was unlocked and kept free of obstruction in case of emergencies. The administrator confirmed that the fire department checked the fire extinguishers, smoke detectors, and carbon monoxide alarms during fire clearance inspection. It also appeared that all utilities were fully functional. Overall, the facility appears to be clean, safe, and in good repair.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CULTURAL MANOR SENIOR LIVING
FACILITY NUMBER: 331880965
VISIT DATE: 03/02/2021
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Pre-Licensing inspection is complete and this facility has no deficiencies. LPA completed Component III presentation with Administrator at the conclusion of the inspection. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed and a copy was provided to Pierce via email.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
LIC809 (FAS) - (06/04)
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