331881324-7-20-2022-18-AS-CCON-CGHQ5K-20220720115203

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881324
Report Date: 07/20/2022
Date Signed: 07/20/2022 11:52:23 AM

Document Has Been Signed on 07/20/2022 11:52 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:	EXECUTIVE RESIDENTIAL CARE & RECOVERY LLC		FACILITY NUMBER:	331881324
ADMINISTRATOR:	TAYLOR, SUSAN 0		FACILITY TYPE:	772
ADDRESS:	70806 HALPER LAKE		TELEPHONE:	(562) 755-9734
CITY:	RANCHO MIRAGE	STATE: CA	ZIP CODE:	92270
CAPACITY: 6		CENSUS: 0	DATE:	07/20/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Susan Taylor - Applicant		TIME COMPLETED:	12:00 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) Crystal Colvin arrived at the facility for the purpose of conducting a Pre-Licensing visit. Analyst met with Applicant Susan Taylor, who LPA Colvin informed of the purpose of today's visit, and toured the facility with the applicant. Fire Clearance was granted for six (6) ambulatory residents on 4/13/22 by the Rancho Mirage Fire Department. Home is set-up with living room, family room, kitchen, dining room, four (4) resident bedrooms, one staff lounge/isolation bedroom, 3 restrooms, office, backyard, laundry room, and a garage. LPA Colvin observed required accommodations in residents' bedroom and bathrooms, including beds, linen, storage furniture, and lamps. LPA Colvin observed that two resident bedrooms did not include a closet, but the facility has sufficient storage furniture (armoire or dresser) to meet storage requirements. LPA Colvin did recommend rearrangement of storage furniture to ensure that each room has an appropriate amount of storage space for the residents (remove dressers from rooms with closets into rooms without closets). LPA Colvin additionally observed a passageway from one of the resident bedrooms to the staff office. Applicant assured LPA Colvin that the passageway will not be used by staff while residents occupy the bedroom, and that the office is accessible through two other doors which connect to the garage and the outside. LPA Colvin recommended for the facility to install a lock on the door with the locking mechanism to be controlled from the bedroom, to ensure resident privacy. Applicant additionally stated they plan to add signs to the door to remind staff not to enter through resident's room. Smoke detectors and carbon monoxide units are all operable, as observed by LPA Colvin when applicant tested them. Common areas such as dining and living rooms were observed to be clean and in good condition. ADMINISTRATION/MEDICATION: A locked standing cabinet is present in the office for medication and record storage. Staff records will include documentation on training for medication administration for all staff and will be kept in the office or in electronic file storage.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

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: EXECUTIVE RESIDENTIAL CARE & RECOVERY LLC	FACILITY NUMBER: 331881324
	VISIT DATE: 07/20/2022

NARRATIVE

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PHYSICAL PLANT: Outside premises were inspected for potential hazards. The facility backyard includes a pool which currently has a standard pool cover. The applicant is prepared to purchase a pool cover/net which can been secured to the ground through drilled in rings that will attach to the cover. LPA Colvin reviewed a photo of the proposed net/cover as well as the facility's pool safety policy and schedule for staff removing the net/cover and assigned staff for designated supervision. LPA Colvin reviewed Title 22 Regulations and approved the plan for the safety net/cover for the pool. LPA Colvin additionally observed that there is no fence separating the backyard of the facility from the neighboring golf course. Title 22 Regulations do not require a fence surrounding the entire premises, but LPA Colvin did advise the Applicant to be prepared for potential outside persons wandering onto the grounds.

LPA Colvin observed the facility to have an indoor wine cellar, which the facility plans to utilize as additional food storage. LPA Colvin advised the facility to add a light near the entrance of the wine cellar, as it is set lower into the foundation of the building and has three stairs going down into the cellar. Applicant agreed and additionally suggested possibly adding a gate for additional precaution. Outside gates were observed to be unlocked for clients' and staff's use in case of emergency as an exit. Exit route from backyard was observed to be free of obstruction. LPA Colvin tested the facility's hot water and observed it to be measuring at 122.9 degrees. LPA Colvin advised the applicant to lower the temperature of the hot water heater slightly to help ensure it does not exceed 120 degrees but is at least 105 degrees.

ACTIVITIES: Inside and outside, there are areas for residents to use for their leisure. Backyard is in good condition with outdoor furniture and a shaded area for the residents. Facility additionally has magazines, tv, books, games, and exercise equipment for residents' use.

FOOD SERVICE: The kitchen area was observed for the ability to serve food and cleanliness. Trash can has tight-fitting lid. Dishes, utensils and glasses are present and in sufficient number for residents and staff. Dishwasher will be used to clean and sanitize dishes. Knives will be kept locked and out of clients' reach for safety purposes, as well as cleaning chemicals. All need appliances were present and shown to be in working condition and clean. Facility has both perishable and non-perishable supply of food to satisfy the 2 day and 7-day requirements as well as additional emergency food storage in the garage.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

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: EXECUTIVE RESIDENTIAL CARE & RECOVERY LLC	FACILITY NUMBER: 331881324
	VISIT DATE: 07/20/2022

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EMERGENCY EXIT PLAN: Facility has an emergency exit plan in place a posted in plain view at the facility, along with operational smoke detectors and carbon monoxide detectors, and fire extinguishers. Applicant has completed and submitted a Mitigation Plan for Infection Control for the facility as well.

Items for Correction: Prior to LPA Colvin providing Centralized Applications Bureau (CAB) of a passing Pre-Licensing Inspection, the Applicant shall make the following corrections/adjustments to the facility:

· Pool cover/net installation
· Adjust hot water temperature to be between 105 - 120 degrees at the warmest.
· Move storage furniture (dressers) to ensure each resident bedroom has at least 8 cubic feet of storage for each resident, if a closet is not present in the bedroom.
· Locks added to resident bedroom adjoining office (recommended but not required)
· Signs on resident bedroom adjoining office regarding not to use as passageway (recommended but not required)

Analyst will inform Centralized Applications Bureau (CAB) about the Pre-Licensing visit and Applicant will be notified of the license approval once the above corrections have been made.

An exit interview was conducted with Applicant Susan Taylor and a copy of the report was provided.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC809 (FAS) - (06/04)

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