336423557-6-15-2023-18-AS-KBAG-CSTPPP-20230615112953

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336423557
Report Date: 06/15/2023
Date Signed: 06/15/2023 11:30:09 AM

Document Has Been Signed on 06/15/2023 11:30 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:	SENIOR HOME PROFESSIONAL CARE 1		FACILITY NUMBER:	336423557
ADMINISTRATOR:	CORNELIO & S. EVANGELISTA		FACILITY TYPE:	740
ADDRESS:	45010 DESERT FOX DRIVE		TELEPHONE:	(760) 834-8140
CITY:	LA QUINTA	STATE: CA	ZIP CODE:	92253
CAPACITY:	6	CENSUS: 6	DATE:	06/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Administator, Sarah Evangelista		TIME COMPLETED:	11:45 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) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that six (6) clients reside at this facility and there are currently (3) staff members present. Facility administrator, Sarah Evangelista came to conduct (S1) and gave the facility tour. There is an Infection Control Plan on file. Client Records-Incident Reports/Clients Rights-Information/Dental- LPA began review of client records. Four (4) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/and Staffing- LPAs began review of employee records- Three (3) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification. The administrator certification is current, Administrator Sarah Evangelista expiration date is 09/02/2025. Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen. (Continued on LIC809C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SENIOR HOME PROFESSIONAL CARE 1	FACILITY NUMBER: 336423557
	VISIT DATE: 06/15/2023

NARRATIVE

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(Continuation from LIC809)

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 106.5 degrees F. Laundry facilities and a locked room is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA observed a facility phone, and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home. The fireplace is not operable and secured. The pool is secured by a 5-foot-high fence and was locked.

Medications- are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. Medications reviewed appear to have been dispensed accurately.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. 6 smoke detectors & 1 carbon monoxide were tested and found to be operational. There were two (2) fire extinguisher bought 11/01/2022. The administrator stated that the last emergency disaster was done on 04/02/2023. The fire drills were done 04/02/2023.

Based on the information received during this visit today in the areas reviewed, there are zero (0) deficiencies observed per Title 22, Division 6 of The California Code of Regulations.
This LIC 809 was reviewed with and a copy will be provided to the administrator.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

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