331881164-10-27-2023-18-AS-JARA-CWZQ9U-20231027115854

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881164
Report Date: 10/27/2023
Date Signed: 10/27/2023 11:59:07 AM

Document Has Been Signed on 10/27/2023 11:59 AM - 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:	RUBIO HOME		FACILITY NUMBER:	331881164
ADMINISTRATOR:	RODRIGUEZ, SHAYLA		FACILITY TYPE:	735
ADDRESS:	51800 AVENIDA RUBIO		TELEPHONE:	(760) 972-4194
CITY:	LA QUINTA	STATE: CA	ZIP CODE:	92253
CAPACITY: 4		CENSUS:	DATE:	10/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Staff, Vincent Ortiz		TIME COMPLETED:	12:15 PM

NARRATIVE

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On 10/19/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Staff, Vincent Ortiz, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (1) resident present. The resident were on an outing in the community at the time of the visit.

The facility is a one story home with attached garage. No firearms or pools are present at the facility. The home has (4) bedrooms and (2) bathrooms. The clients served are adults ages 18 to 59 years of age. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following:

Infection Control: The LPA observed hand washing stations with hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan to train staff on infection control guidelines, however no documented plan was present at the facility at the time of the visit. Technical advisory note was documented with due date.

Physical Plant: Physical plant was not in good repair with toilet and walls in hallway and resident room needing repairs. Technical advisory note was documented with repair due date. The indoor and outdoor areas were observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide were operational.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. The food supply was low at the facility, technical note was documented as the facility staff where on their way to purchase groceries at time of visit.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

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: RUBIO HOME	FACILITY NUMBER: 331881164
	VISIT DATE: 10/27/2023

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Record Review and Resident/Staff Files: LPA reviewed staff files and training. All staff possess a cleared background. Staff have updated training along with CPR/First Aid Certification. The administrator change which occurred two months prior according to staff was not reported to the department. This was cited and plan of correction was created with staff. Resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in kitchen pantry. LPA reviewed resident medications which had all required documentation and labeling.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. Technical note was documented for facility to update this plan to new department requirements, due date was documented. The last fire drill was conducted 7/28/23, tecnical note was documented for facility to conduct a drill by the end of the month. LPA observed emergency exits and emergency supplies.

No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was reviewed and provided to Staff, Vincent Ortiz.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/27/2023 11:59 AM - It Cannot Be Edited

Created By: Janira Arreola On 10/27/2023 at 11:38 AM

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: RUBIO HOME	FACILITY NUMBER: 331881164
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85061(b)

85061 Reporting Requirements (b) The licensee shall notify the licensing agency, in writing, within 30 days of a change of administrator. Such notification shall include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with change in administrator that was not reported to the department. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	The staff agreed to send the required notification to the LPA by the POC due date.

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:

Rikesha Stamps

LICENSING EVALUATOR NAME:

Janira Arreola

LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC809 (FAS) - (06/04)

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