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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881329
Report Date: 09/15/2023
Date Signed: 09/15/2023 02:21:13 PM


Document Has Been Signed on 09/15/2023 02:21 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:CARLOTTA, THEFACILITY NUMBER:
331881329
ADMINISTRATOR:BOWIE, MOLLYFACILITY TYPE:
741
ADDRESS:41-505 CARLOTTA DRIVETELEPHONE:
(760) 346-5420
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY:250CENSUS: 177DATE:
09/15/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Helen Kim, Health Services DirectorTIME COMPLETED:
02:20 PM
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On 9/15/2023, Licensing Program Analyst (LPA), Chinwe Nwogene, conducted an unannounced visit to the facility to conduct a case management visit to address an incident involving the death of Resident One (R1). LPA met with Health Services Director, Helen Kim and Executive Director, Molly Bowie who was informed of the purpose of the visit.

The Department received a death report from the facility on 9/14/2023 regarding the client's death on 9/14/2023. A subsequent death report has not been received according to Helen Kim. According to Helen, on 8/24/2023, resident went on a drive with husband who is also a resident at the facility, and both got into a car accident. Helen reported both were transferred to the hospital and haven’t been back at the facility since then. Molly further stated residents Responsible Party notified facility yesterday 9/14/2023 of resident one (R1) passing. Residents files were reviewed and revealed residents are able to leave facility unassisted.

No information was received by the LPA to indicate there was any lack of care and/or supervision. No citations have been issued at this time. This report was reviewed with Helen Kim and a copy was provided.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023
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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