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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880999
Report Date: 06/26/2024
Date Signed: 06/26/2024 12:27:02 PM


Document Has Been Signed on 06/26/2024 12:27 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:MD PREMIER CARE HOMEFACILITY NUMBER:
331880999
ADMINISTRATOR:DOLHA, MIRCEAFACILITY TYPE:
740
ADDRESS:45911 PASEO CORONADOTELEPHONE:
(949) 335-2364
CITY:INDIAN WELLSSTATE: CAZIP CODE:
92210
CAPACITY:6CENSUS: 4DATE:
06/26/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Licensee, Mircea DolhaTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. LPA met with Licensee, Mircea Dolha. LPA was informed that four (4) residents currently reside at this facility. There were two (2) staff members on duty, during the time of the visit.

LPA toured the facility and observed all facility utilities to be on and operating without issue, food supply is sufficient, there is no immediate concern for residents in care.

Licensing Program Analyst (LPA) Kathleen Banrasavong spoke to the Licensee, Mircea Dolha regarding the Incident Report submitted to Community Care Licensing Riverside Regional Office on June 24, 2024. The incident occurred on 06/19/2024. It was reported that Resident 1 (R1) passed away from a heart problem due to a UTI. The LPA reviewed and requested documents pertinent to R1’s medical health condition.

Based on the information obtained during today’s visit, there are no deficiencies or civil penalties being cited per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Licensee, Mircea Dolha and a copy of this report is left with him, as evidence by his signature.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024
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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