331881249-2-28-2022-18-AS-JSEN-CC3REV-20220228115809

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881249
Report Date: 02/28/2022
Date Signed: 02/28/2022 11:58:19 AM

Document Has Been Signed on 02/28/2022 11:58 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:	SALTON VIEW ASSISTED LIVING		FACILITY NUMBER:	331881249
ADMINISTRATOR:	JONES, ANTONIA		FACILITY TYPE:	740
ADDRESS:	12171 SALTON VIEW ROAD		TELEPHONE:	(951) 529-5728
CITY:	WHITEWATER	STATE: CA	ZIP CODE:	92282
CAPACITY:	6	CENSUS: 0	DATE:	02/28/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Doug and Antonia Jones		TIME COMPLETED:	12:16 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jennifer Semin conducted a pre-licensing inspection and Component III. LPA met with Licensees/Administrators, Doug and Antonia Jones. The application is for a Residential Care Facility for the Elderly for 2 (two) ambulatory residents, 2 (two) non ambulatory resiodents and 2 (two) bedridden residents and a hospice waiver for 6 (six). A tour of the pending facility was conducted inside and out. Overall, the pending facility is clean and good condition. There are no pools, bodies of water, firearms or ammunition. LPA observed the bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, showers and tubs have grab bars and non-skid mats. Mr. Jones stated the propane tank will be filled between 3/1/2022 to 3/14/2022, therefore LPA was unable to measure the water temperature. Licensee will notify LPA once this has been completed. LPA observed food storage and preparation areas are clean and sanitary. Refrigerator and freezer temperatures are maintained at appropriate temperatures. LPA observed a seven (7) day supply of nonperishable food and a two (2) day supply of perishable food. All appliances are clean and operating properly. There is a sufficient supply of linens, towels and personal hygiene items. The First Aid kit and manual were ordered while LPA was present. Licensee will notify LPA once these items have been received. LPA observed a minimal supply of recreation and leisure items and activities but licensee states he plans to add a variety of recreation and leisure items based on their resident’s preferences, once admitted. The property is completely enclosed with functioning gate to exit to the street. Outdoor space is suitable for resident use that includes a table with umbrella and chairs. The fire extinguisher has been recently serviced and is completely charged. Smoke alarms and carbon monoxide detectors are present and functional. Medications will be centrally stored and secured in a locked cabinet. All hazardous materials such as, cleaning and disinfecting supplies, knives and other sharps are locked and inaccessible to residents. All required forms will be posted in a common area once received. LPA verified the order was placed. Licensee will notify LPA once these items have been received and posted.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

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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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: SALTON VIEW ASSISTED LIVING	FACILITY NUMBER: 331881249
	VISIT DATE: 02/28/2022

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Pre-Licensing is incomplete with issues to be resolved by 3/14/2022. A follow up Pre-licensure LIC809 will be generated upon resolution of issues.
Mr and Ms. Jones were reminded of the statute that requires the licensee to contact LPA at CCLD 951-473-7024 within 5 business days of admitting their first resident. This notification may be done by phone, mail or fax.
An exit interview was conducted where this report was discussed and provided to Mr. and Ms. Jones.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

LIC809 (FAS) - (06/04)

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