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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424662
Report Date: 09/06/2024
Date Signed: 09/09/2024 07:51:14 AM


Document Has Been Signed on 09/09/2024 07:51 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:TRINITY GARDENS ON PORTOLAFACILITY NUMBER:
336424662
ADMINISTRATOR:GREGORY O HOLTAFACILITY TYPE:
740
ADDRESS:44-277 PORTOLA AVENUETELEPHONE:
(760) 568-4333
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:15CENSUS: 8DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee Gregory Otto HoltaTIME COMPLETED:
02:00 PM
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On 9/6/24 Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced one (1) year required visit. LPA were granted entry by caregiver, Nicole Delorge, who was informed of the purpose of visit. At the time of the visit there were three (3) staff, Licensee/Administrator and eight (8) residents present. All staff present were observed to have obtained proper fingerprint clearance and were associated to the facility. LPA observed the following during today's visit:

LPA conducted a tour of the facility with staff member, Nicole Delorge. The facility has a dining room, kitchen, great room, and a gated backyard. Indoor and outdoor passageways were free of obstruction. There were no bodies of water located on the property. The facility has more than a two (2) day supply of perishable foods and seven (7) day supply of non-perishable foods. Water temperature measured at 113.8-degree Fahrenheit. LPA observed an additional freezer with non-perishable foods in the garage and hallway. Emergency food is stored on a rack located in the garage. Dishes and utensils were in sufficient supply and in good repair. Knives and sharp items are located in the kitchen in a locked drawer. Resident bedrooms had the required bedding, furniture, and lighting. Disinfectants and cleaning solutions were secured in a locked cabinet under the kitchen sink. Kitchen and food preparation areas were free of litter and rubbish. LPA observed a fully charged fire extinguishers. Bathrooms were equipped with the required railing and non-skid mats. Centrally stored medication was observed in a locked cabinet located.



Staff files reviewed have a criminal record clearance, personnel record, Activities of Daily Living (ADL) training's, and valid first aid/CPR certification. Resident files included but are not limited to signed admission agreements, appraisals, physician reports, and needs and service plans. Facility sketch, personal rights, see something say something, license and LTCO poster are posted on the walls throughout the facility. According to Licensee, Otto, there are no firearms or ammunition on the premises.
During today's visit, LPA did not observe any immediate violations or concerns. An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee, Otto.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Valerie FloresTELEPHONE: (951) 248-0308
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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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