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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412798
Report Date: 01/12/2024
Date Signed: 01/12/2024 02:44:46 PM


Document Has Been Signed on 01/12/2024 02:44 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: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:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrator, Analisa CayabyabTIME COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with, Administrator, Analisa Cayabyab, who was informed of the purpose of the visit. At time of visit there were (9) clients and (3) staff present.

The facility is a one story home with (6) bedrooms and (3) bathrooms with attached garage. The facility does have a pool which has a locked gate surrounding it. No fire arms are kept at the facility. The facility is designated as a residential care facility for the elderly serving elderly 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 in the facility hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards and contained outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. 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 115F.

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 StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AFFINITY SENIOR LIVING 1
FACILITY NUMBER: 336412798
VISIT DATE: 01/12/2024
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Record Review and Resident/Staff Files: LPA reviewed staff files and training that contained staff criminal clearance and CPR/First Aid. The annual training for (2) staff were not available for review during the time of the visit. Deficiency was cited and plan of correction was documented with staff. Technical advisory note was documented for staff to provide the written staff schedule to LPA. Resident files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in a cabinet. LPA reviewed client medications for residents and found all medication listed and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA was informed the last drill was conducted in April of 2023. Deficiency was cited for facility to conduct drills when required. Plan of correction was created with administrator. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where this report, deficiency page, and appeal rights were reviewed and provided to Administrator, Analisa Cayabyab.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/12/2024 02:44 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: AFFINITY SENIOR LIVING 1
FACILITY NUMBER: 336412798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based oninterview and record review, the licensee did not comply with the section cited above with (2) staff files that did not have the documented annual 20 hours of training which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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The administrator stated they would send these copies to the LPA by the POC due date.
Type B
Section Cited
CCR
1569.695(c)
(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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above with not having the required amount of drills per year which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
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The adminsitrator stated they would have the drill conducted and documentation would be sent to LPA by the 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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4