331881523-6-12-2024-18-AS-JGEE-D66Q4H-20240612115022

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881523
Report Date: 06/12/2024
Date Signed: 06/12/2024 11:50:31 AM

Document Has Been Signed on 06/12/2024 11:50 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:	SHILOH LIVING LLC		FACILITY NUMBER:	331881523
ADMINISTRATOR:	ANDERSON, MARK D		FACILITY TYPE:	740
ADDRESS:	43629 PARKWAY ESPLANADE W		TELEPHONE:	(760) 996-9958
CITY:	LA QUINTA	STATE: CA	ZIP CODE:	92253
CAPACITY:	6	CENSUS: 0	DATE:	06/12/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:36 AM
MET WITH:	Mark Anderson, Licensee/Administrator		TIME COMPLETED:	12:00 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) Javina George made an announced visit to the facility for the purpose of conducting a prelicensing inspection. LPA met with Licensee Mark Anderson and whom accompanied LPA for the duration of the inspection. On 2/7/24 the city of La Quinta Fire department granted a fire clearance, that will allow the home to be licensed to have six (6) non-ambulatory residents, with an approved hospice waiver for 2. The facility is a single story home with five (5) bedrooms, and four (4) bathrooms, attached garage, kitchen, backyard, and great room/family room. LPA conducted a tour of the interior and exterior of the facility. The following was observed during today's inspection: The facility has a sufficient supply of dishes, cooking and eating utensils, and linens that were observed to be in good repair. The facility food supply was observed to be sufficient as there was 2 day supply of perishable and a 7 day supply of nonperishable food items. The facility has an emergency food and water supply. The bathrooms were equipped with grab bars and non skid mats. The hot water was tested in all four bathrooms and measured to be between 113.9-117.5 degrees Fahrenheit. There are no pools or bodies of water on the premises. The passageways, and ramps/inclines were clear and free from obstruction. The home has five (5) fully charged fire extinguishers. There are smoke and carbon monoxide detectors strategically placed throughout the facility that were tested and observed to be operable. The facility does not have any known guns or ammunition stored on grounds. The sharps/knives, and chemicals are stored in a locked cabinet inside the laundry room. The medications will be kept in lock boxes, that will stored in a locked cabinet inside the great room/living room. LPA observed for the rooms to be fully furnished with a bed, lamp, night stand, and adequate lighting. The hallways had adequate lighting equipped with night-lights. The facility has working flashlights easily accessible (plugged into the outlets) to use in the event of a power outage. The facility was observed to have

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

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: SHILOH LIVING LLC	FACILITY NUMBER: 331881523
	VISIT DATE: 06/12/2024

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the required postings (resident council, theft and loss policy, personal rights, PUB475 CCL complaint poster. The Long term Care Ombudsman poster is posted on the wall in the dining room.

The facility was observed to have several activities to encourage socialization such as, puzzles, bingo, as well as a covered patio with plenty of outdoor space including a putting green.

It is the recommendation that the home be licensed once the following is completed:
-Successful completion of COMP III orientation, (scheduled 6/14/24)
-Complete first aid kit-items needed: thermometer, tweezers, gauze), and current first aid manual-ordered and will be delivered tomorrow 6/13/24, per receipt reviewed
-Sharps/bio hazardous container-ordered and will be delivered tomorrow 6/13/24, per receipt reviewed
-Liability insurance (pending license number)

An exit interview was conducted and a copy of this report was provided to Mark Anderson, Licensee/Administrator.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC809 (FAS) - (06/04)

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