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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881609
Report Date: 09/06/2024
Date Signed: 09/09/2024 07:57:09 AM

Document Has Been Signed on 09/09/2024 07:57 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:COUNTRY VIEW HOME CALIENTEFACILITY NUMBER:
331881609
ADMINISTRATOR/
DIRECTOR:		DIANA, JOCELYNFACILITY TYPE:
735
ADDRESS:13809 CALIENTE DR,TELEPHONE:
(760) 799-5464
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY: 6CENSUS: 0DATE:
09/06/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Applicant Jocelyn DianaTIME VISIT/
INSPECTION COMPLETED:
10:35 AM
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On 9/6/24 Licensing Program Analyst (LPA) Valerie Flores made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA Flores met with Applicant Jocelyn Diana, who accompanied LPA for the tour of the facility. The Applicant has submitted an application to attain a capacity of (6) six residents. On 8/21/24 the Riverside County Fire Department approved a fire clearance for the six (6) ambulatory.

The facility is a single-story structure building consisting of one (1) staff room, three (3) residents' bedrooms, (2) bathrooms, a kitchen, formal dining room, living room, 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 hall closet. LPA observed a fully charged fire extinguisher. A locked cabinet in the kitchen was observed to store disinfectant, poisons, and other cleaning solutions. The carbon monoxide and smoke detector were tested and were observed to be operable and in good working condition. The facility has more than a two (2) day supply of perishable foods and seven (7) day supply of non-perishable foods. Kitchen/food preparation areas were kept clean from litter and rubbish. The outdoor patio is shaded and furnished. The facility has a sufficient supply of dishes, cooking and eating utensils, that were observed to be in good repair. Centrally stored medication is kept in a locked cabinet that is inaccessible to residents in care. All indoor and outdoor passageways were free of obstruction. The hot water temperature was measured at 120.3 degrees Fahrenheit meeting the required limits. The facility has an emergency disaster plan and approved infection control training plan on file. Per Applicant Jocelyn, there are no firearms or ammunition on the premises.

Continuation on LIC809C...
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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: COUNTRY VIEW HOME CALIENTE
FACILITY NUMBER: 331881609
VISIT DATE: 09/06/2024
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LPA observed the required postings of the emergency disaster plan, resident personal rights, employee rights, visitor policy, facility sketch, CCL Complaint poster and the Long-Term Care Ombudsman poster posted on the walls throughout the facility.

During today's visit, LPA Flores did not observe any issues or concerns. Final approval of licensure will be determined by Centralized Application Bureau (CAB). A exit interview and a copy of this report was given to Applicant Jocelyn.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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