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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881148
Report Date: 11/17/2023
Date Signed: 11/17/2023 07:47:58 PM

Document Has Been Signed on 11/17/2023 07:47 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:LEVI HOMEFACILITY NUMBER:
331881148
ADMINISTRATOR:GARCIA, JESSEFACILITY TYPE:
735
ADDRESS:73463 GUADALUPE AVENUETELEPHONE:
(760) 600-7020
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY: 4CENSUS: 3DATE:
11/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
06:30 PM
MET WITH:Staff, Christina RiosTIME COMPLETED:
08:00 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Staff, Christina Rios who was informed of the purpose of the visit. At the time of the visit there were three (2) staff and three (3) residents present. LPA spoke with administrator, Sandra Hernandez over the phone.

The facility is a one story home with (3) bathrooms and (4) bedrooms. No pools or fire arms are kept at the facility. The facility serves adults ages 18 to 59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Infection Control: LPA observed the hand washing stations with hand hygiene supplies and hand washing signs. The facility has a plan on mitigating infectious diseases and training staff. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility.

Physical Plant: LPA observed the resident bedrooms and bathrooms. Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility was observed to be free of any hazards. Laundry equipment was observed to be in good repair. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature read 116.7F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LEVI HOME
FACILITY NUMBER: 331881148
VISIT DATE: 11/17/2023
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Record Review and Resident/Staff Files: One (1) staff file was not available for review during the time of the visit. Technical advisory note was documented for administrator to send this file to LPA. Resident files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: Resident medication were locked in a medication cart inside a locked medication room. LPA reviewed resident medications for residents and found all medication were accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last disaster drill conducted 10/21/23. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where a copy of this report was provided to Staff, Christina Rios.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
LIC809 (FAS) - (06/04)
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