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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881242
Report Date: 11/03/2021
Date Signed: 11/03/2021 12:50:06 PM

Document Has Been Signed on 11/03/2021 12:50 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:
(951) 683-6596
CITY:INDIOSTATE: CAZIP CODE:
92201
CAPACITY: 49CENSUS: 46DATE:
11/03/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Jones Ntekin & Applicant Theresa BaderTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility for the purpose of conducting a second Pre-Licensing visit. LPA Colvin met with Administrator Jones Ntekim and Licensee representative Theresa Bader. The facility is currently in operation under another license and is undergoing a change of ownership.

The building is equipped with 28 bedrooms, 4 common bathrooms accessible to residents (in addition to multiple resident bedrooms equipped with personal bathrooms), common areas, medication room, staff offices and break rooms, dining room and kitchen. Per the approved fire clearance, the licensee is approved for 49 ambulatory residents. LPA Colvin observed resident bedrooms to be furnished with the required items such as dressers, night stands, and beds. The facility has adequate quantity of linens, towels and hygiene products for residents. LPA Colvin measured the hot water in one of the common bathrooms and observed it to read at 114.8 degrees. The smoke and carbon monoxide alarms were tested on 10/12/21 by the Fire Marshall, and are equipped to notify the local Fire Department immediately upon signal. LPA observed fire doors to be properly functioning. Fire extinguishers are present in the facility and fully charged.

The kitchen was observed to have dishes, silverware, pots, and pans. LPA Colvin observed the temperature of the freezers in the kitchen to be reading at 14 degrees and the refrigerators to be reading at 34 degrees. All appliances are operational, and the facility has sufficient amount of both perishable and non-perishable food, and LPA Colvin additionally observed the facility to be receiving a food delivery during LPA Colvin's inspection. Knives and potentially harmful chemicals are generally locked and out of reach of residents in storage. Laundry facilities are available for residents to use with staff assistance, as well as additional lcoked laundry facilities for staff to clean residents' linen. Staff and resident files will be locked in a file cabinet in the office.

Medications are locked in the medication room, which is staffed and secured beyond another office.LPA Colvin observed a miniature refrigerator in the medication room as well, which is operational.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DESERT SAGE
FACILITY NUMBER: 331881242
VISIT DATE: 11/03/2021
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The facility was observed to have plenty of seating and activity room for residents both inside and outside, including shaded areas outside with benches and tables.

An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Jones Ntekim and Licensee representative Theresa Bader.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC809 (FAS) - (06/04)
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