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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412147
Report Date: 09/18/2024
Date Signed: 09/24/2024 12:48:45 PM


Document Has Been Signed on 09/24/2024 12:48 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:GOLDLUXURY VILLAFACILITY NUMBER:
336412147
ADMINISTRATOR:LILIBETH GRABOWSKIFACILITY TYPE:
740
ADDRESS:79105 ARBOLA CIRCLETELEPHONE:
(760) 469-3934
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:6CENSUS: 6DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Lilibeth Grabowski, AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card.

Resident record review began- Two (2) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 108.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location.



Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized.

LPA began review of employee records- Two (2) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, some documents missing from file and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current. (Continued on next page)
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GOLDLUXURY VILLA
FACILITY NUMBER: 336412147
VISIT DATE: 09/18/2024
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(Continued on from page 1)

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation; however review of records revealed three (3) residents are on hospice and a waiver is approved for two (2) and the structure is changed according to the approved floor plan; During tour the LPA observed there is a staff room located in a portion of the garage which is converted, LPA research revealed in 2016, an LPA documented the licensee must submit a revised facility sketch and approved permit for this alteration. The LPA instructed the licensee to submit this information to licensing by 07/13/2016, Licensee stated she submitted. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 02/22/2024. The facility is conducting emergency disaster drills; not quarterly. The last disaster drill was conducted on 06/29/2024.

LPA allocated time to prepare this report for delivery.

Based on the information received during this visit today, there four (4) deficiencies is being cited per Title 22, Division 6 of The California Code of Regulations.

This report was reviewed with and a copy provided to the facility representative. Appeal Rights were also provided at the time of the exit interview.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/24/2024 12:48 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: GOLDLUXURY VILLA
FACILITY NUMBER: 336412147

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in which three (3) residents are on hospice care and facility has an approved waiver for two (2) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2024
Plan of Correction
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Licensee will request an increase for hospice capacity to four (4) and submit a request to assigned LPA by POC due date.
Type B
Section Cited
CCR
87412(b)(3)(B)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following: (3) For volunteers that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no documentation of a criminal record clearane observed in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2024
Plan of Correction
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Licensee will ensure documentation is in staff file and email a copy to LPA by POC due date.
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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/24/2024 12:48 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: GOLDLUXURY VILLA
FACILITY NUMBER: 336412147

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in drills are being documented every six months identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2024
Plan of Correction
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Licensee will ensure facility is conducting diaster drills every quarter and email LPA a schedule of drills for the next 12 months by POC due date.
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in first aide supplies including wound care cleanser was in a closet unsecured and not locked which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2024
Plan of Correction
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Licensee will replace door knob with a locked knob to ensure residents do not have accessed and email picture of lock to LPA by POC due date.
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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4