336425030-6-1-2023-18-AS-KBAG-CSDR45-20230601124059

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425030
Report Date: 06/01/2023
Date Signed: 06/01/2023 12:41:56 PM

Document Has Been Signed on 06/01/2023 12:41 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	AVATAR RETIREMENT HOME		FACILITY NUMBER:	336425030
ADMINISTRATOR:	JAMAL ALKAWASS		FACILITY TYPE:	740
ADDRESS:	44645 SAN ONOFRE AVENUE		TELEPHONE:	(760) 340-5191
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92260
CAPACITY:	10	CENSUS: 8	DATE:	06/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Facility Manager, Angel Sanchez		TIME COMPLETED:	12:40 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 eight (8) clients reside at this facility and there are currently (2) caregivers present. The facility manager, Angel Sanchez gave the facility tour. LPA observed one staff (S1) in the kitchen prepping food. Upon asking for the employee’s identification, facility manager stated that the staff was not working or associated with the facility. There is not an Infection Control Plan on file. LPA advised facility that they need to have a infection control plan on file. Client Records-Incident Reports/Clients Rights-Information/Dental- LPA began review of client records. Three (3) 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- Two (2) 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; expiration date 07/11/2023. 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 chemicals and 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: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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: AVATAR RETIREMENT HOME	FACILITY NUMBER: 336425030
	VISIT DATE: 06/01/2023

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 105.0 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. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home. There is no pool and no bodies of water observed. The fireplace is not operable and 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. The facility pre-plans medication that are to be dispensed to the residents in a container. LPA informed the facility manager that per regulations, they must dispense medication based on the prescription and cannot preplan the medication. The facility manager agreed for best practices they would implement a centrally stored medication file.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. 15 smoke detectors and 15 carbon monoxide detectors were tested and found to be operational. The fire alarm and carbon monoxide is a 2 in 1 system, are bi-operational. There were two (2) fire extinguisher last was recharged, 10/15/2021. LPA advised the facility manager that the fire extinguisher was expired and for best practice they should get the fire extinguishers replaced. The facility is conducting emergency disaster/fire drills monthly; last done on 03/24/2023.

(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: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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: AVATAR RETIREMENT HOME	FACILITY NUMBER: 336425030
	VISIT DATE: 06/01/2023

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Based on the information received during this visit today in the areas reviewed, there are 1 type A deficiency 87355(e) that will be assessed with an civil penalty being cited per Title 22, Division 6 of The California Code of Regulations. LPA and facility managed collaborated and agreed to have the 2 fire extinguisher replaced, an infection control plan in place, and review of the regulations regarding having any person(s) not cleared in the facility. The facility has agreed to have a plan of corrections emailed to the LPA by June 9, 2023.

This LIC 809 was reviewed with and a copy will be emailed and mailed to the facility representative and a confirmation of receipt will be requested.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 06/01/2023 12:41 PM - It Cannot Be Edited

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: AVATAR RETIREMENT HOME	FACILITY NUMBER: 336425030
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

Section Cited

CCR

87355(e)

This requirement is not met as evidenced by: Facility having an unassociated, uncleared person in facility prepping food.
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/01/2023
	Plan of Correction
1 2 3 4	The facility had removed the staff (S1) immediately.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

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