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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424396
Report Date: 08/21/2020
Date Signed: 09/08/2020 01:51:50 PM

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:SEGOVIA OF PALM DESERTFACILITY NUMBER:
336424396
ADMINISTRATOR:SCHAFFER II, ERNEST CFACILITY TYPE:
741
ADDRESS:39905 VIA SCENATELEPHONE:
(760) 674-3200
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:182CENSUS: 143DATE:
08/21/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
05:50 PM
MET WITH:Ernie Shaffer, Executive DirectorTIME COMPLETED:
06:15 PM
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**Due to a computer malfunction, a handwritten report had to be issued. This is an exact duplicate of that handwritten report. See handwritten document in file for original signatures.**

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility on this day for the purpose of issuing an immediate exclusion letter. LPA met with Executive Director (ED) Ernie Shaffer. LPA provided ED a copy of "Immediate Exclusion of Karen Martinez Valenzuela" letter. LPA also toured the facility and verified Karen Martinez Valenzuela was not present. ED also stated this staff is on call and not on the schedule for the next couple of weeks. LPA requested ED submit a request to disassociate Karen Martinez Valenzuela.



An exit interview conducted and a copy of this report and exclusion letter was provided to ED.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020
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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