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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881242
Report Date: 05/16/2022
Date Signed: 05/16/2022 11:10:56 AM

Document Has Been Signed on 05/16/2022 11:10 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: 48DATE:
05/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jones Ntekim - AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of following up on the death of an Adult Resident (R1), who passed on 5/14/22. LPA Colvin met with Administrator Jones Ntekim and informed him of the purpose of today's visit. Theresa Bader, Chief of Training for MFI Recovery (Licensee) additionally arrived during LPA Colvin's visit to assist with providing information regarding R1.

LPA Colvin interviewed Administrator Ntekim about the events leading up to R1's passing, R1's medical history, and other relevant information. LPA Colvin additionally reviewed R1's file and requested copies of paperwork for R1 and staff present at the time of R1's passing. Additional information may be needed from the facility as Licensing looks into R1's passing, and additionally follow up by assigned LPA Jesse Gardner may be required.

An exit interview was conducted with Administrator Jones Netkim and a copy of this report was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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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