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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881629
Report Date: 09/05/2024
Date Signed: 09/05/2024 11:27:49 AM

Document Has Been Signed on 09/05/2024 11:27 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:MISSION AT DESERT SERENITY IIFACILITY NUMBER:
331881629
ADMINISTRATOR/
DIRECTOR:		CAMPBELL, CAMILLAFACILITY TYPE:
735
ADDRESS:68896 CORRAL RDTELEPHONE:
(909) 328-9790
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 4CENSUS: 0DATE:
09/05/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Camilla Campbell, applicantTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Seo Jeon made an announced visit to the facility for the purpose of conducting a prelicensing inspection. LPA met with Applicant, Camilla Campbell, who accompanied LPA for the inspection. The Applicant has submitted an application for 4 residents (4 non ambulatory). On 7-22-2024, the Riverside County Fire Department approved a fire clearance for which the applicant has applied for.

The home is a single story structure consisting of 4 bedrooms, 3 bathrooms, kitchen, dining room, family room and attached garage. There is no swimming pool or body of water in the facility. The bedrooms were observed to have bed, lighting, night stand, chest of drawers and area for sitting. The bathrooms had nonskid mats and grab bars. There is plenty of extra linen (sheets, blankets, towels) that were observed to be in good repair. The smoke and carbon monoxide detectors are a dual system that were tested and found to be operable.

The hot water temperature was tested and was found to be within regulatory limits measuring at 110 degrees Fahrenheit. The facility is equipped with flashlights and night lights. The facility has an emergency disaster plan and infection control training plan on file. The facility has a sufficient supply of dishes, cooking and eating utensils, 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. There is a fully stocked first aid kit.

The passageways, and ramps/inclines are clear and free from obstruction. The home has 1 fully charged fire extinguisher with current tag. The facility does not have any known guns or ammunition stored on grounds. The sharps/knives are stored in a locked cabinet in the kitchen. The medications will be kept in individual boxes that will be stored in a locked cabinet located in staff room.

Continued on LIC809-C.....
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: MISSION AT DESERT SERENITY II
FACILITY NUMBER: 331881629
VISIT DATE: 09/05/2024
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Upon entry to the home in the hallway wall, the required postings (facility sketch, resident council, theft and loss policy, personal rights, PUB475 CCL/dept complaint poster and the Long Term Care Ombudsman poster were observed to be posted.

The facility was observed to have activities to encourage socialization such as, board games, arts & crafts as well as a covered patio with plenty of outdoor space for walking and physical activities.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA determined the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete, and this facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to applicant, Camilla Campbell.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC809 (FAS) - (06/04)
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