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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881459
Report Date: 10/26/2023
Date Signed: 10/26/2023 12:47:52 PM


Document Has Been Signed on 10/26/2023 12:47 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:
331881459
ADMINISTRATOR:BOWIE, MOLLYFACILITY TYPE:
741
ADDRESS:41-505 CARLOTTA DRIVETELEPHONE:
(760) 346-5420
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY:250CENSUS: 204DATE:
10/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Executive Director, Molly BowieTIME COMPLETED:
01:00 PM
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On 10/26/2023, Licensing Program Analyst (LPA) Janira Arreola made an unannounced visit to the facility for the purpose of a case management visit involving a recent death. LPA met with, Executive Director, Molly Bowie, who was informed of the purpose of the visit.

At the time of the visit, LPA conduct a facility walk through and a health and safety check on facility residents. LPA requested pertinent documented related to Resident 1 (R1)'s death, admission agreement and physician's report. Administrator was informed of documentation that would need to be sent to the regional office as soon as it is available. LPA conducted interviews with staff and residents during the visit.

No health or safety issues were found during the visit.

An exit interview was conducted where this report was reviewed and provided to Executive Director, Molly Bowie.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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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