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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881242
Report Date: 07/08/2024
Date Signed: 07/08/2024 12:31:33 PM

Document Has Been Signed on 07/08/2024 12:31 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DESERT SAGEFACILITY NUMBER:
331881242
ADMINISTRATOR/
DIRECTOR:
JOSSYE TRIVINO-COOKFACILITY TYPE:
735
ADDRESS:82485 MILES AVETELEPHONE:
(442) 324-2629
CITY:INDIOSTATE: CAZIP CODE:
92201
CAPACITY: 49CENSUS: 49DATE:
07/08/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Residential Program Administrator, Jossye CookTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Kathleen Banrasavong made an unannounced visit to conduct a case management visit for Resident 1 (R1)’s death. LPA conducted a health and safety check and met with Residential Program Administrator, Jossye Cook and Acting Administrator/Residential Manager, Blanca Santamaria and explained the purpose of today’s visit. At the time of the LPA’s visit, there was 48 (forty-eight) residents at the facility and 6 (six) staff members present at the time of the visit.

During the LPA’s visit, LPA reviewed, requested, and obtained copies of pertinent documentation, conducted staff interviews regarding R1’s death on 07/04/2024. LPA interviewed to obtained further information regarding the death of R1 and the events that led up to R1’s death. The cause of death is unknown at this time, to the facility. LPA advised the Residential Program Administrator, Jossye Cook and Acting Administrator/ Residential Manager, Blanca Santamaria to send a copy of the death certificate to the department, as soon as it becomes available.

No deficiencies were cited during this visit, as there were no health and safety concerns observed during today's visit.

An exit interview was conducted and a copy of this report (LIC 809) and LIC 811 (confidential names list) were provided to the Residential Program Administrator, Jossye Cook

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2024
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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