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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881242
Report Date: 10/04/2022
Date Signed: 10/04/2022 01:12:04 PM

Document Has Been Signed on 10/04/2022 01:12 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
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: 45DATE:
10/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jossye Cook, Program Director TIME COMPLETED:
11:27 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner arrived to the facility unannounced to follow-up on information reported to the Department on 8/1/2022 in reference to a client (C1) who was given an eviction notice on 6/20/2022.

LPA met with Program Director Jossye Cook, and explained the circumstances of the visit. LPA conducted a record review, and found that during the visit to the facility on 8/1/2022, the facility was not given a citation in reference to the eviction not being reported to the Department within 5 days.

Therefore, LPA cited the facility for not reporting the eviction within 5 days, and documented the citation on LIC809-D.

An exit interview was conducted where a copy of this report was discussed with and provided to Cook along with a copy of the LIC811.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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 10/04/2022 01:12 PM - It Cannot Be Edited


Created By: Jesse Gardner On 10/04/2022 at 11:15 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: DESERT SAGE
FACILITY NUMBER: 331881242

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2022
Section Cited
CCR
80068.5(e)

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Eviction Procedures: (e) The licensee shall mail or fax to the Department a copy of the 30-day written notice in accordance with (a) above within five days of giving the notice to the client. This was not being met as evidenced by:
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Licensee states that they will submit written procedures on how they will notify all parties regarding evictions. Licensee to also rescind the original eviction letter in writing and submit to CCL by POC date.
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Based on interview, Licensee did not report the incident within 5 days of giving the notice. Licensee stated that the eviction was given on 6/20/22, and reported to the Department on 8/1/22 during the visit. This poses a potential health and safety or personal rights risk to residents in care.
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022


LIC809 (FAS) - (06/04)
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