331881007-4-19-2023-18-AS-JGEE-CR2ST7-20230419140903

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881007
Report Date: 04/19/2023
Date Signed: 04/19/2023 02:09:14 PM

Document Has Been Signed on 04/19/2023 02:09 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:	PURE HOPE CARE		FACILITY NUMBER:	331881007
ADMINISTRATOR:	FADDOUL, LEVI		FACILITY TYPE:	740
ADDRESS:	78740 SANITA DRIVE		TELEPHONE:	(661) 810-7293
CITY:	LA QUINTA	STATE: CA	ZIP CODE:	92253
CAPACITY:	6	CENSUS: 6	DATE:	04/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Levi Faddoul, Administrator		TIME COMPLETED:	02:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Javina George conducted an unannounced annual/1 year required visit on 04/19/2023 at 10:30am. LPA was granted entry by Caregiver Evita Chow, who was informed of the purpose of the visit. The Administrator Levi Faddoul arrived shortly after.

The facility is a single story home with (3) bedrooms and (2) bathrooms designated for the residents and there is one (1) bedroom and one (1) bathroom available for staff to use. LPA conducted a tour of the interior and exterior of the facility and observed the following:

Infection Control: The LPA observed the hand washing stations in the bathrooms. LPA also observed gloves at the facility and sharps container for needles.

Physical Plant: LPA observed the clients bedrooms which contained the required furniture and personal rights postings. The interior and the exterior were observed to be clean, odor and clutter free. floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair. The facility does not have a pool or any other bodies of water on the premises. The water temperature was tested and was found to be within regulatory limits 109.2-115.9 degrees Fahrenheit.

Food Service: LPA observed the kitchen to be clean and possess equipment in good working condition. LPA observed the facility had the required 2-day perishable and 7-day non-perishable food supplies. The sharp and dangerous objects are kept locked in the kitchen in a drawer in a black tool box next to the refrigerator and or stove.

Care & Supervision/Administration: Adequate staff are present for the supervision of residents. At the time of LPA's visit there were two (2) observed caregivers for the six (6) residents in care. Emergency exiting plans, emergency telephone numbers and personal rights were found posted in the facility on the wall inside of the dining area.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

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: PURE HOPE CARE	FACILITY NUMBER: 331881007
	VISIT DATE: 04/19/2023

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Record Review and Resident/Staff Files: LPA observed staff had current CPR/First Aid Certification. The six (6) resident files were also found to be completed with the required Physician reports (LIC 602), and appraisals there is one resident that has their appointment on 4/27/23 to get their updated 602. Additionally, LPA conducted (2) staff and (3) resident interviews. The staff were able to answer the questions with some additional clarification.

Incidental Medical: LPA reviewed the medications for (3) residents and found that all resident medications were accounted for, with proper labeling, and medication administration log was found to be accurate and up to date.

Disaster Preparedness: The facility has record of conducted emergency drills (earthquake, fire, flood). Per Administrator Levi, the drills are conducted on a quarterly basis and the last drill was on 1/1/23, and it was a fire drill. The facility's fire alarms (4) and(1) carbon monoxide detectors were tested and are operable. LPA observed there to be one fire extinguisher on the premises located in the dining area.

An exit interview was conducted where a copy of this report was reviewed and provided to Administrator Levi Faddoul.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/07/2024 10:40 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/04/2024 02:19 PM

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: PURE HOPE CARE	FACILITY NUMBER: 331881007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2023
	Plan of Correction
1 2 3 4	This D page was never provided to the Administrator, as the emergency disaster drills were located and provided to LPA to review. There was no deficiency issued, as the D page was generated in error, therefore no signature was obtained.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Tricia Danielson	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC809 (FAS) - (06/04)

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