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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881028
Report Date: 04/12/2024
Date Signed: 04/12/2024 02:50:16 PM

Document Has Been Signed on 04/12/2024 02:50 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:MENTAL WELLNESS KS INC.FACILITY NUMBER:
331881028
ADMINISTRATOR/
DIRECTOR:		MCLAUGHLIN, ERICFACILITY TYPE:
772
ADDRESS:502 N. CERRITOS RDTELEPHONE:
(310) 402-4911
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY: 6CENSUS: 1DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Cherita Beard - Program ManagerTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Program Manager Cherita Beard and informed her of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents.

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin observed the facility to be a comfortable temperature of 74 degrees. LPA Colvin measured the hot water in the occupied resident bedroom and observed it to be measuring at 129.2 degrees. Deficiency cited. LPA Colvin did not observe any obstructions to emergency exits or hallways/walkways. LPA Colvin observed staff testing the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives and dangerous chemicals were locked in the staff office. The facility has an in-ground pool in the backyard which LPA Colvin observed to be covered.

Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 ambulatory residents.

Incidental Medical Services: LPA Colvin observed that resident medication is locked in a designated medication closet and is inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. LPA Colvin additionally reviewed medications for all residents and did not observe any concerns during today's inspection.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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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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: MENTAL WELLNESS KS INC.
FACILITY NUMBER: 331881028
VISIT DATE: 04/12/2024
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Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin confirmed staff have criminal record clearance and have training to perform their required duties. Staff records are kept off-site at corporate, but they were able to provide LPA Colvin with electronic access to specific forms requested. LPA Colvin reviewed records for five staff members and confirmed that those staff have current CPR/First Aid Certification and have other relevant documents completed in their files.

Resident Records: LPA Colvin reviewed the file for the current resident to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin observed that the facility's only current resident did not have a Needs & Services Plan yet in their electronic chart, however, since the resident was just admitted 4/11/24, the facility is still within the 72 hour time frame to complete the document.

Food Services: LPA Colvin observed the facility to have the required amount of perishable and non-perishable food. LPA Colvin observed the kitchen and dining area to be maintained in a clean and healthful manner. Sufficient dishware and silverware was present for residents use. The facility's freezer was observed to be 0 degrees and the refrigerator was 36 degrees.

Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file and conducts regular Emergency Disaster drills.

An exit interview was conducted with Program Manager Cherita Beard and a copy of this report, LIC809D, and appeal rights were provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/12/2024 02:50 PM - It Cannot Be Edited


Created By: Crystal Colvin On 04/12/2024 at 02:40 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: MENTAL WELLNESS KS INC.
FACILITY NUMBER: 331881028

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation], the licensee did not comply with the section cited above in 1 resident bathroom which poses an immediate health, safety or personal rights risk to persons in care. LPA Colvin observed the hot water in the resident bathroom to be 129.2 degrees.
POC Due Date: 04/13/2024
Plan of Correction
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Program Manager agrees to have hot water tempurature adjusted and to measure the hot water to ensure it is between 105-120 degrees. Program Manager may self-ceritfy to LPA Colvin once complete. Due by Plan of Correction due date of 4/13/24.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024


LIC809 (FAS) - (06/04)
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