331881503-1-17-2024-18-AS-KBAG-CZKS9Q-20240117124107

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881503
Report Date: 01/17/2024
Date Signed: 01/17/2024 12:41:14 PM

Document Has Been Signed on 01/17/2024 12:41 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	TRANQUIL SPRINGS CRT		FACILITY NUMBER:	331881503
ADMINISTRATOR:	BLUM, CHRISTOPHER		FACILITY TYPE:	772
ADDRESS:	47915 OASIS ST STE C		TELEPHONE:	(501) 337-7950
CITY:	INDIO	STATE: CA	ZIP CODE:	92201
CAPACITY: 15		CENSUS: 0	DATE:	01/17/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Administrator, Christopher Blum		TIME COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation. LPA met with Administrator, Christopher Blum. An initial application to operate a Social Rehabilitation facility (SRF) was submitted to the Central Applications Bureau (CAB) on 11/28/2023 for a total capacity of fifteen (15) residents. Fire clearance was granted on 11/14/2023. LPA Kathleen Banrasavong observed the following:

Structure:

Facility is a one-story building with seven (7) client resident’s bedrooms, which will room two clients and one (1) single client bedroom, six (6) women resident’s bathrooms, living room, dining area and kitchen. There is not a garage. There is not a pool. There was an outside storage area to the west side of the building. There is an outside gate that leads to the northeast side of the building.

Heating/Cooling System:

Central heating and air conditioning system are installed and operable. The temperature for the building is controlled in a centrally stored area within the whole building.

Bedrooms:

Each resident bedroom #12, #13, #14, #15, #18, #19, #20, #21 were in good repair. All eight (8) bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable centrally located smoke alarm for the entire building, with two alarm pulls and three (3) carbon monoxide alarms.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TRANQUIL SPRINGS CRT	FACILITY NUMBER: 331881503
	VISIT DATE: 01/17/2024

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Bathrooms:

Six (6) resident’s bathrooms have a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and hand soap dispensers. LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 108 degrees Fahrenheit.

Kitchen/Laundry:

An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp drawer will be secured in a locked drawer located in the cabinet. There was adequate room for food storage. LPA observed the stove and microwave to be operational. Refrigerator/freezer were in working condition. Pantry had sufficient storage for non-perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in the garage. Laundry detergents and cleaning supplies were observed in a closet away from residents.

Living/Family room:

There was a living room with furniture for all clients.

Linens and Hygiene Supplies:

An adequate supply of linens and hygiene supplies was stored in a cabinet in the hallway of the facility in room C05.

Yards/Outside: Patio table and chairs were observed in the backyard. All outdoor pathways were free of obstructions. There is an outside gate that leads to the northeast side of the building.

Emergency Phone Numbers, and Exit Plan, Personal rights, the facility sketch was observed and posted at the facility. Let-Us-No poster was observed.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TRANQUIL SPRINGS CRT	FACILITY NUMBER: 331881503
	VISIT DATE: 01/17/2024

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General items:

Two (2) fire extinguisher was charged on 03/16/2023. Every room has an alarm that is centrally connected to the building’s fire monitoring system. Client records will be stored in the nurse’s section. Three (3) First Aid kits with required components were observed. There was a locked area for medication storage. Emergency food and water supply was observed. One (1) AED defibrillation machine. Pre-Licensing is complete, and this facility has no deficiencies.

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

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC809 (FAS) - (06/04)

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