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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881401
Report Date: 09/04/2024
Date Signed: 09/05/2024 08:36:04 AM

Document Has Been Signed on 09/05/2024 08:36 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AXIS DESERT HOT SPRINGS - AFACILITY NUMBER:
331881401
ADMINISTRATOR/
DIRECTOR:		LANG, PAULFACILITY TYPE:
772
ADDRESS:66563 5TH STREET, BUILDING ATELEPHONE:
(339) 293-9066
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY: 6CENSUS: 0DATE:
09/04/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Paul LangTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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On 9/4/24 Licensing Program Analyst's (LPA) Valerie Flores and Abdoulaye Zerbo made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA's Flores and Zerbo met with Administrator Paul Lang, who accompanied LPA's for the tour of the facility. The Applicant has submitted an application for (6) six residents to which applicant can only accept ambulatory residents. On 6/15/23 the Riverside County Fire Department approved a fire clearance for the six (6) ambulatory.

The facility is a single-story structure building consisting of three (3) residents' bedrooms, (5) bathrooms, a kitchen, formal dining room, game room, supply room, four (4) staff offices, and garage. The bedrooms were observed to have met the required bedding lighting, and furniture. There are plenty of extra linen (sheets, blankets, towels) that were observed to be in good repair located in the supply room. A fully charged fire extinguisher located on the exterior of building A. A locked supply room was observed to store disinfectant, poisons and other cleaning solutions. Three (3) locked cabinets were observed in Unit 2 for centrally stored medication and storing knives and other sharp objects. The carbon monoxide and smoke detector were tested and were observed to be operable and in good working condition. The kitchen is equipped with four (4) refrigerators. Each refrigerator met the required temperature per regulations.

The hot water temperature was measured at 118.2 degrees Fahrenheit meeting within the required limits. The facility has an emergency disaster plan and approved infection control training plan on file. The facility has a sufficient supply of dishes, cooking and eating utensils, that were observed to be in good repair. Indoor and outdoor passageways were free of obstruction. There are no bodies of water observed on the premises. Per Administrator Paul Lang, there are no firearms or ammunition on the premises.

LPA's observed the required postings of the emergency disaster plan, resident personal rights, employee rights, facility sketch, and See Something Say Something located on a wall in Unit 2.



Continuation on LIC809C...
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AXIS DESERT HOT SPRINGS - A
FACILITY NUMBER: 331881401
VISIT DATE: 09/04/2024
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During today's visit, LPA's Flores and Zerbo did not observe any issues or concerns. Applicant completed COMP III in August of 2024. Final approval of licensure will be determined by Centralized Application Bureau (CAB). A exit interview and a copy of this report was given to Administrator Paul.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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