336412698-1-13-2023-18-AS-JARA-CN2W47-20230113155705

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336412698
Report Date: 01/13/2023
Date Signed: 01/13/2023 03:57:16 PM

Document Has Been Signed on 01/13/2023 03:57 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:	AFFINITY SENIOR LIVING 2		FACILITY NUMBER:	336412698
ADMINISTRATOR:	ANALISA CAYABYAB		FACILITY TYPE:	740
ADDRESS:	28200 HORIZON ROAD		TELEPHONE:	(760) 864-3259
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY:	9	CENSUS: 8	DATE:	01/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Administrator, ANALISA CAYABYAB,		TIME COMPLETED:	04:00 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) Janira Arreola, made an unannounced visit on 1/13/2023 at 02:30 p.m. in order to conduct an annual visit with a focus on infection control. LPA met with Administrator, ANALISA CAYABYAB, who was informed of the purpose of the visit. At the time of the visit there were (4) staff and (8 residents present. LPA proceed to conduct a walk through of the facility's interior and exterior. LPA observed there was a central entry point for facility visits. LPA observed COVID-19 postings at the facility. The facility has a 30-day supply of PPE equipment that is readily accessible for residents and staff. LPA observed the resident bedrooms that would be used as isolation rooms. The resident bathrooms were observed to be clean and have the appropriate hand hygiene supplies such as hand sanitizer, soap, running water and paper towels. The facility has a cleaning plan in place to disinfect and clean the high touch surfaces of the facility and the isolation rooms. The staff have leave in case of contact or testing positive for COVID-19. The staff have been trained on how to properly don and doff the PPE equipment, and there is a plan of care in place to attend to those residents that would be in the isolation rooms. The staff have also been FIT tested for an N95 respiratory and will be due for their annual test. LPA was informed that the facility is no longer taking temperatures for staff and visits. LPA will document a technical advisory note, that administrator was advised to conduct temperature checks on a regular basis for visitors and staff at the beginning of their shift.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

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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Document Has Been Signed on 01/13/2023 03:57 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: AFFINITY SENIOR LIVING 2	FACILITY NUMBER: 336412698
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above with cleaning supplies that were observed to be unclocked in the facility restrooms. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/14/2023
	Plan of Correction
1 2 3 4	The Licensee will provide the LPA with training material that shall be conducted with facility staff. The training material shall include the following topics: proper storage of cleaning solutions. The training shall also cover proper storage of dangerous items for indivudals with Dementia. The training material and staff sign-in sheet shall be emailed to LPA by the POC due date.

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: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AFFINITY SENIOR LIVING 2	FACILITY NUMBER: 336412698
	VISIT DATE: 01/13/2023

NARRATIVE

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LPA observed cleaning chemicals in restroom #1 under the sink that were unlocked. The cabinet draw had a lock that was not properly lacking making the cleaning supplies accessible to the facility residents. LPA observed (1) can of powdered bleach under the sink in restroom #2 that was place on top of the resident hygiene supplies. This cabinet did not have a lock on it. LPA also observed cleaning products under the sink in the master bedroom that were also unlocked. LPA had administrator move cleaning supplies to a locked area and was able to do so immediately. LPA will be documented a Type A citation for the unlocked cleaning supplies observed as well as a plan of correction.

An exit interview was conducted where this report was reviewed and provided to Administrator, ANALISA CAYABYAB.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

LIC809 (FAS) - (06/04)

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