<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423741
Report Date: 11/04/2022
Date Signed: 11/04/2022 11:25:47 AM

Document Has Been Signed on 11/04/2022 11:25 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SVS-PALM SPRINGS ADULT DAY PROGRAMFACILITY NUMBER:
336423741
ADMINISTRATOR:KENNISHA CAREYFACILITY TYPE:
775
ADDRESS:997 E. TAHQUITZ CANYON WAYTELEPHONE:
(310) 944-3303
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY: 45CENSUS: DATE:
11/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:ADMINISTRATOR, CAREY KENNISHA TIME COMPLETED:
11:30 AM
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
On November 04, 2022, Licensing Program Analyst (LPA), Venus Mixson made an unannounced case management health and safety visit to the above facility. LPA Mixson met with Administrator, Kennisha Carey and explained the purpose of the visit.

LPA Mixson toured the facility and interviewed Administrator, one staff, and requested pertinent documentation. LPA received documentation.

LPA Mixson toured the facility. At the time of the visit there were 45 residents and 7 caregivers. There are no imminent health and/or safety concerns observed at the time of visit. LPA observed all facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well.

Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. However, deficiencies were cited during today's visit for lack of supervision while out on an outing.

An exit interview was conducted and a copy of this report, Rights of Appeal,

along with the LIC 811, was provided to Administrator.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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 2
Document Has Been Signed on 11/04/2022 11:25 AM - It Cannot Be Edited


Created By: Venus Mixson On 11/04/2022 at 10:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SVS-PALM SPRINGS ADULT DAY PROGRAM
FACILITY NUMBER: 336423741

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2022
Section Cited
CCR
80078A

1
2
3
4
5
6
7
80078 A Care and supervision -Facility shall provide care and supervision Clients must be supervised at all times. Facility failed to do this by:

1
2
3
4
5
6
7
Administrator shared that all staff would be trained on care and supervision of facility clients at all times. The training log would be fax to LPA by 11/14/2022.
8
9
10
11
12
13
14
Leaving Clients unsupervised while on an outing. This poses an immediate health and safety risk to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Venus Mixson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2