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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423557
Report Date: 06/13/2022
Date Signed: 06/13/2022 03:57:56 PM


Document Has Been Signed on 06/13/2022 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:SENIOR HOME PROFESSIONAL CARE 1FACILITY NUMBER:
336423557
ADMINISTRATOR:CORNELIO & S. EVANGELISTAFACILITY TYPE:
740
ADDRESS:45010 DESERT FOX DRIVETELEPHONE:
(760) 834-8140
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:6CENSUS: 4DATE:
06/13/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Sarah Evangelista, LicenseeTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA), Chinwe Nwogene made an unannounced visit to the facility to conduct an annual inspection.

During the visit LPA observed one more staff member present without the proper clearances. Staff #2 (S2) reported having had worked for the Licensee for approximately one (1) month. S2 reported having had fingerprints done but, LPA observed SSN on the fingerprint clearance form in S2 file is different from S2 actual SSN card. Deficiency and civil penalty issued for both staff (S1) and (S2).

An exit interview was conducted, and a copy of this report was reviewed and provided to Sarah Evangelista.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
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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