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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881007
Report Date: 02/07/2025
Date Signed: 02/07/2025 04:07:18 PM

Document Has Been Signed on 02/07/2025 04:07 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:PURE HOPE CAREFACILITY NUMBER:
331881007
ADMINISTRATOR/
DIRECTOR:		FADDOUL, LEVIFACILITY TYPE:
740
ADDRESS:78740 SANITA DRIVETELEPHONE:
(760) 834-8242
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY: 6CENSUS: 4DATE:
02/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Caregiver Evita ChowTIME VISIT/
INSPECTION COMPLETED:
04:17 PM
NARRATIVE
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Licensing Program Analyst (LPA) Armando Perez arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that four (4) clients live at this facility and home at the time of the inspection. There was two (2) staff members present. The Administrator, Levi Faddoul spoke to the LPA on the phone. The caregiver, Evita Chow will assist with the inspection.

LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility consists of three (3) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, a kitchen and dinning area, a living room area, a garage and laundry room, and a patio and yard with sufficient seating and space for activities. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured within regulation. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home and no bodies of water observed. LPA observed a room that had a non-working light, and will need to be serviced. A technical assistance was issued.

LPA began review of client records. Three (3) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA was not able to review files for 1 resident. Administrator stated over the phone that file is in a locked cabinet and cannot be provided at the time of visit. A deficiency will be cited.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 02/07/2025 04:07 PM - It Cannot Be Edited


Created By: Armando Perez On 02/07/2025 at 03:19 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: PURE HOPE CARE
FACILITY NUMBER: 331881007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above in two out of four staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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Administrator will be faxing or emailing a completed file for LPA to review for Luz Lorenzana Benitez, Levi Faddoul and maintain her records at the facility at all times.
Type B
Section Cited
CCR
87412(e)
Personnel Records
(e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation record review, the licensee did not comply with the section cited above in missing the LIC 500 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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LPA could not verify the staff and shift coverages for the week. Administrator will provide a completed LIC 500 Personnel roster and will maintain it at the facility.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Armando Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/07/2025 04:07 PM - It Cannot Be Edited


Created By: Armando Perez On 02/07/2025 at 03:19 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: PURE HOPE CARE
FACILITY NUMBER: 331881007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above in one out of four clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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Administrator will need to email or fax a completed file for Patricia Wolff. File was not available at teh time of visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jazmond D Harris
LICENSING EVALUATOR NAME:Armando Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PURE HOPE CARE
FACILITY NUMBER: 331881007
VISIT DATE: 02/07/2025
NARRATIVE
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LPA began review of employee records- Two (2) records were available for review. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 06/06/2026. LPA observed one employee on site who did not have a file and was not on the Guardian roster. LPA confirmed employee had fingerprints cleared and will need to be transferred over to facility. LPA provided LIC 9192 and clearance number to submit request. A technical violation was cited. LPA could not verify employee files for administrator and one employee. A deficiency will be cited. LPA could not review a completed LIC 500 and could not confirm the personnel roster and the shift coverage. A deficiency will be cited.

LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for knives and sharps in the kitchen.

Medications are centrally stored. There is a locked cabinet in the kitchen allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.



LPA made observation throughout the inspection to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers was recently serviced on 01/13/2025. Fire drills are conducted quarterly at the facility.

Based on the information received during this visit today in the areas reviewed, there are deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations and will require a correction.

This LIC 809 report was reviewed with the facility representative and a copy was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
LIC809 (FAS) - (06/04)
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