336403223-11-17-2023-18-AS-JARA-CXP4GP-20231117180553

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336403223
Report Date: 11/17/2023
Date Signed: 11/17/2023 06:06:02 PM

Document Has Been Signed on 11/17/2023 06:06 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:	SERRANO RESIDENTIAL CARE FOR THE ELDERLY		FACILITY NUMBER:	336403223
ADMINISTRATOR:	FRANCES SERRANO		FACILITY TYPE:	740
ADDRESS:	2710 CYPRESS RD.		TELEPHONE:	(760) 325-1537
CITY:	PALM SPRINGS	STATE: CA	ZIP CODE:	92262
CAPACITY:	6	CENSUS: 5	DATE:	11/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Licensee, Frances Serrano		TIME COMPLETED:	06:15 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) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Licensee, Frances Serrano, who was informed of the purpose of the visit. At the time of the visit there were three (3) staff and five (5) residents present. The facility is a one story home with six (6) bathrooms and six (6) bedrooms, approved for two (2) hospice and six(6) non-ambulatory residents. Based on record review and interview, the licensee is retaining resident #1 (R1), whom is bedridden. The facility does not have current approved fire clearance. Deficiency was cited and plan of correction was created with licensee. No pools or fire arms are kept at the facility. The facility serves elderly residents ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Infection Control: LPA observed the hand washing stations with hand hygiene supplies and hand washing signs. The facility has a plan on mitigating infectious diseases and training staff. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. Physical Plant: LPA observed the resident bedrooms and bathrooms. Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility was observed to be free of any hazards. Laundry equipment was observed to be in good repair. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature read 119.3F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

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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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: SERRANO RESIDENTIAL CARE FOR THE ELDERLY	FACILITY NUMBER: 336403223
	VISIT DATE: 11/17/2023

NARRATIVE

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Record Review and Resident/Staff Files: Staff files had all required training, criminal record clearance and required documents. Resident files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: Resident medication were locked in a medication cart inside a locked medication room. LPA reviewed resident medications for residents and found all medication were accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last disaster drill conducted 10/21/23. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where a copy of this report, deficiency pages, and appeal rights were provided to Licensee, Frances Serrano.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 11/17/2023 06:06 PM - It Cannot Be Edited

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: SERRANO RESIDENTIAL CARE FOR THE ELDERLY	FACILITY NUMBER: 336403223
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

(a) …Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved… (2)Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with R1 was currently has a bedridden status, the facility currently is not approved to retain bedridden residents. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/18/2023
	Plan of Correction
1 2 3 4	The licensee agreed to submit a self certified statement that the section cited above was read and understood. The Licensee shall also include a date on when they will submit supporting documentation to retain R1.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC809 (FAS) - (06/04)

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