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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881242
Report Date: 11/07/2022
Date Signed: 11/07/2022 01:18:31 PM

Document Has Been Signed on 11/07/2022 01:18 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: 46DATE:
11/07/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Program Director, Jossye CookTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit in order to conduct a health and safety check due to an incident that happened at the facility. LPA met with Program Director, Jossye Cook who was informed of the purpose of the visit.

LPA conducted a walk through of the interior and exterior of the facility. LPA observed the facilities food supply which was within the 2-day perishable and 7-day non-perishable food items. LPA observed the facility residents that were in the front patio, in their rooms, dining room, and hallways. LPA walked through the kitchen, facility hallways, facility laundry room, and resident rooms and bathrooms. LPA observed Resident #1 (R1)'s room who was involved in the incident. LPA also walked and took pictures of the restroom where the incident occurred. LPA collected documents from the resident's file, facility documents and obtained a summary of events that transpired. The facility will send the department the coroner's report and the death certificate when it becomes available.

LPA reviewed the LIC500 for staff and found that (6) staff were not transferred from Licensee's other facility Roy's Desert Springs Adult Residential Care. LPA checked for Staff #1 (S1), social and date of birth and found that the employee is not in the background check database, LPA will issue a deficiency for S1. This will be document on an LIC809-D page along with the plan of correction. LPA will document Technical advisory note for staff that have not been transferred. Program Director stated this can be completed by Wednesday 11/9/2022. The facility will be issued a civil penalty in the amount of $500 for the uncleared staff.

An exit interview was conducted where this report was reviewed, along with LIC809-D page and appeal rights, and was provided to Program Director, Jossye Cook.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2022
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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Document Has Been Signed on 11/07/2022 01:18 PM - It Cannot Be Edited


Created By: Janira Arreola On 11/07/2022 at 01:02 PM
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: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2022
Section Cited
CCR
80019(e)(1)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or
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The licensee shall ensure this staff is cleared before returning to work at the facility. The Licensee shall send LPA the communication sent to staff stating this by the POC due date.
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Based on interview, and records review the fcaility did not ensure that S1 had a background clearance before beginning to work at the facility.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022


LIC809 (FAS) - (06/04)
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