331881140-4-15-2021-18-AS-TDAN-C24T57-20210415142504

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881140
Report Date: 04/15/2021
Date Signed: 04/15/2021 02:26:21 PM

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:	DOLORES HOMECARE II		FACILITY NUMBER:	331881140
ADMINISTRATOR:	CAYABYAB, ANALISA		FACILITY TYPE:	740
ADDRESS:	68285 ENCINITAS ROAD		TELEPHONE:	(760) 218-8906
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY:	6	CENSUS: 3	DATE:	04/15/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Analisa Cayabyab, Administrator		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tricia Danielson conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 11:00 AM, LPA met with Licensee/Administrator Analisa Cayabyab via FaceTime. An initial application to operate a Residential Care For the Elderly (RCFE) facility was received by the Central Applications Unit (CAU) on 03/3/21 for a total capacity of six (6) non-ambulatory residents, one (1) of which may be bedridden. Fire Clearance was granted on 03/29/2021 for five (5) non-ambulatory residents and one (1) bedridden resident, totaling six (6) non-ambulatory residents. During today's visit, LPA Danielson observed the following: Structure: Facility was a single story house with four (4) resident bedrooms, three (3) resident bathrooms, living room, dining area and kitchen. There was an attached garage in the front of the house. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: Each client bedroom will accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm/carbon monoxide detector. Bathrooms: All three (3) resident bathrooms have a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. LPA verified bathroom water temperatures were measured at 113.1 and 120.0 degrees Fahrenheit. LPA observed toiletries for each resident and were free from commingling. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet. There was adequate room for food storage. LPA (CONTINUED ON LIC 812C)

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

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: DOLORES HOMECARE II	FACILITY NUMBER: 331881140
	VISIT DATE: 04/15/2021

NARRATIVE

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(CONTINUED FROM LIC 812)
observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all residents. Laundry area with washer and dryer was located in the garage.
Living/Family room:
There was a living room with safe and adequate seating for all residents as well as working TV.
Linens and Hygiene Supplies:
An adequate supply of additional linens and hygiene/medical supplies were stored in a hallway cabinet.
Yards/Outside:
There was a patio with adequate covered seating for all residents. All walkways were observed to be free of obstructions.
Garage:
Garage was free of obstructions. Laundry soap was secured in a locked cabinet. An additional freezer was observed for additional food storage.
Emergency Phone Numbers, and Exit Plan:
Let-Us-No poster, emergency phone numbers, emergency exit plan, resident Personal Rights, and facility visitation policy were posted as required.
General items:
One (1) fire extinguisher was charged and mounted in the hallway. Smoke alarms and carbon monoxide detectors were tested and were in working order. Emergency lighting was observed throughout the facility. Resident records were stored in a locked closet. First Aid kit with required components, and locked area for medication storage was observed. LPAs observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Component III was completed at Licensee's sister facility in 2005.

The following deficiencies require resolution:
Licensee to obtain 72 hour supplies and water for self reliability in the event of an emergency
Licensee to ensure the side gate is self latching
Pre-Licensing is incomplete with deficiencies to be resolved by 4/19/2021. A follow up Pre-licensure LIC809 will be generated upon resolution of deficiencies.
An exit interview was conducted and a copy of this report was provided via email. Licensee has agreed to sign it and return a copy to LPA.

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

LIC809 (FAS) - (06/04)

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