<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881242
Report Date: 08/01/2022
Date Signed: 09/02/2022 09:19:35 AM

Document Has Been Signed on 09/02/2022 09:19 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DESERT SAGEFACILITY NUMBER:
331881242
ADMINISTRATOR:NTEKIM, JONESFACILITY TYPE:
735
ADDRESS:82485 MILES AVETELEPHONE:
(442) 324-2629
CITY:INDIOSTATE: CAZIP CODE:
92201
CAPACITY: 49CENSUS: 47DATE:
08/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jossye Cook, DirectorTIME COMPLETED:
12:20 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) Jesse Gardner conducted an unannounced visit to the facility to follow-up on an incident reported to the Department on 07/29/2022. LPA met with Manager Blanca Santamaria. LPA conducted an inspection of the facility, interviewed staff and residents and reviewed resident files during the visit.

On 7/29/22 the facility reported Resident 1 (R1) had ignited their mattress on fire that same morning, at approximately 10:30 am. Facility reported no one was injured in the fire and that the Fire Department was able to clear the area without further incident. Information gathered during the visit revealed R1 started the fire by igniting an aerosol can of disinfectant spray R1 had in their room. Per facility staff residents are not to have any chemicals in their room. LPA also learned that R1 was issued an eviction notice by the facility on 06/20/22, however the facility did not notify the Department of the eviction as required by Title 22.

Based on information obtained during the visit the facility is being issued a citation for failure to report the incident to the Department, for resident having access to chemicals and for the facility’s failure to report the eviction of a resident to the Department.

An exit interview was conducted and a copy of this report, along with LIC 809D and Appeal Rights were reviewed with and provided to Manager Blanca Santamaria.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/02/2022 09:22 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/01/2022 04:36 PM


Created By: Jesse Gardner On 08/01/2022 at 11:37 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DESERT SAGE
FACILITY NUMBER: 331881242

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2022
Section Cited
CCR
80087(g)

1
2
3
4
5
6
7
80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not being met as evidenced by:
1
2
3
4
5
6
7
Licensee states that a review of the regulation will be conducted as well as training by staff and will self-certify that the regulation is understood by submitting an email to LPA by POC date.
8
9
10
11
12
13
14
Based on LPA's interview with residents and staff, LPA learned that R1 had access to an Aerosol Can inside of her room. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
09/09/2022
Section Cited
CCR80061(b)(1)(E)

1
2
3
4
5
6
7
80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.(1) Events reported shall include the following:(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement was not being met as evidenced by:
1
2
3
4
5
6
7
Licensee states that both incident reports will be sent to CCL by POC date, along with training for staff on reporting incidents will be conducted and submitted to LPA also by POC date.
8
9
10
11
12
13
14
Based on LPA record review, LPA discovered that the facility did not report the incident in which R1 had attempted to light a fire to a curtain in their room. An eviction was given in relation to the incident on 6/20/22. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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:Deborah Mullen
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2