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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412798
Report Date: 08/22/2023
Date Signed: 08/22/2023 10:08:56 AM


Document Has Been Signed on 08/22/2023 10:08 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:AFFINITY SENIOR LIVING 1FACILITY NUMBER:
336412798
ADMINISTRATOR:ANALISA CAYABYABFACILITY TYPE:
740
ADDRESS:68842 RISUENO ROADTELEPHONE:
(760) 322-7905
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:10CENSUS: 9DATE:
08/22/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Caregiver, Gloria AntonioTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. LPA met with the caregiver, Gloria Antonio. LPA was informed that nine (9) residents currently reside at this facility, with a capacity of ten (10). There were two (2) staff on duty during the time of the visit.

LPA toured the facility and observed all facility utilities to be on and operating without issues. Food supply is sufficient. There is no immediate concern for residents in care. LPA observed R1's medication at the facility. LPA did not observe R1's files at the facility. LPA spoke to the Administrator, Anson Cayabyab on the phone regarding R1’s files; (physician report, written record of care, and emergency information). The Administrator stated that he will have the files at the facility where R1 resides by August 23, 2023.

No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Caregiver, Gloria Antonio and a copy of this report is left with the her as evidence by her signature.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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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