331881435-6-1-2023-18-AS-YDEO-CSDQSS-20230601122602

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881435
Report Date: 06/01/2023
Date Signed: 06/01/2023 12:26:27 PM

Document Has Been Signed on 06/01/2023 12:26 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MD PREMIER 2 CARE HOME		FACILITY NUMBER:	331881435
ADMINISTRATOR:	DOLHA, MIRCEA		FACILITY TYPE:	740
ADDRESS:	45385 MESA COVE		TELEPHONE:	(949) 335-2364
CITY:	INDIAN WELLS	STATE: CA	ZIP CODE:	92210
CAPACITY:	6	CENSUS: 0	DATE:	06/01/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Mircea Dolha, Administrator		TIME COMPLETED:	12:30 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) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:35 AM, LPA met with Licensee/Administrator Mircea Dolha. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 2/24/2023 for a total capacity of six (6) non-ambulatory residents. Fire clearance was granted on 04/11/2023. LPA Delgado observed the following: Structure: Facility is located inside a gated community and is a one story house with six (6) resident bedrooms, four (4) resident bathrooms, living room, dining area and kitchen. One (1) caregiver room and one (1) Administrator room next to the garage. There was an attached two car garage in the front of the house. Heating/Cooling System: Central heating and air conditioning system installed with two panels located in the hallway of the bedroom area to control bedrooms and the wall in the dining area to control the rest of the house. Bedrooms: Each resident bedroom #1, #2, #3, #4, #5 and #6 will accommodate one (1) non-ambulatory resident. Three (3) of Six (6) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. Bathrooms: Four (4) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and hand soap dispensers missing . At 10:15 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 111.3 degrees Fahrenheit. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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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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: MD PREMIER 2 CARE HOME	FACILITY NUMBER: 331881435
	VISIT DATE: 06/01/2023

NARRATIVE

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(CONTINUED FROM LIC 809)

and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the house. Laundry detergents and cleaning supplies were observed in closet away from residents.
Living/Family room:
There was a living room with furniture for all clients and TV.
Linens and Hygiene Supplies:
An adequate supply of linens and hygiene supplies was stored in a cabinet in the hallway of the residence.
Yards/Outside:
Patio table and chairs were observed in the backyard. There was a gate on the North side and S/E side of the property with a self-latching lock. All outdoor pathways were free of obstructions. There is a in-ground pool with a black fencing for the perimeter observed.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted at the exits in the house. Obudsman poster, Let-Us-No poster, Rights of Resident Council, Theft & Loss, Personal rights, Non-discrimination observed.
General items:
Two (2) fire extinguishers were charged and located in the kitchen and in the hallway; missing receipt. Eleven (11) smoke alarms with carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the Kitchen. First Aid kit with required components; no manual observed, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply was observed need additional and the required 72-hour emergency food supply was observed. There were cameras observed in common areas: Dining area, living area, kitchen, hallway and patio.
Component III will be done on June 6, 2023 at 9am at Riverside RO.

(CONTINUED ON LIC809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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: MD PREMIER 2 CARE HOME	FACILITY NUMBER: 331881435
	VISIT DATE: 06/01/2023

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(CONTINUED FROM LIC809C)

Pre-Licensing is incomplete and the following corrections to be resolved by 6/6/2023:

obtain additional emergency water
obtain and post visiting policy
obtain PPE supplies
obtain receipts for fire extinguishers
obtain paper towel dispensers
obtain hand soap dispensers
obtain hand washing signage
obtain additional emergency lightning
cover fireplace for bedroom #3
replace light bulb for patio area
replace window screens
update admission agreement to include cameras in common areas
update plan of operation to include cameras in common areas
Rooms #3,#4 and #6 need to be setup

An exit interview was conducted, and a copy of this report was given.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

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