336425566-6-1-2023-18-AS-KBAG-CSDVZ9-20230601165223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425566
Report Date: 06/01/2023
Date Signed: 06/01/2023 04:52:41 PM

Document Has Been Signed on 06/01/2023 04:52 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:	HOVLEY CARE LLC		FACILITY NUMBER:	336425566
ADMINISTRATOR:	SVETLANA CALAMARO		FACILITY TYPE:	740
ADDRESS:	40827 HOVLEY COURT		TELEPHONE:	(760) 568-4100
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92260
CAPACITY:	6	CENSUS: 4	DATE:	06/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Caregiver, Alicia Sical-Castenada		TIME COMPLETED:	05:00 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 four (4) clients reside at this facility and there are currently (1) caregiver present. Facility caregiver, Alicia Sical-Casteneda (S1) gave the facility tour. LPA later observed one staff (S2) that came into the facility but was not associated through Guardian. The staff had a fingerprint clearance through DOJ in the staff’s file. There is not an Infection Control Plan on file. LPA advised facility that they need to have 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. There was one resident (R1) who has dementia that did not have an updated Physician’s report. LPA advised Alicia Sical-Casteneda that they needed to update that for the facility files and record keeping. 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. The administrator certification is not current and annual fees are not paid. LPA informed the facility representative and administrator over the phone. LPA gave PIN to caregiver to provided to licensee. (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)

Page: 1 of 4

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: HOVLEY CARE LLC	FACILITY NUMBER: 336425566
	VISIT DATE: 06/01/2023

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
26
27
28
29
30
31
32

(Continuation from LIC809)
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.
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 106.0 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 a pool with a 5 foot locked gate around the perimeter. The fireplace is not operable and secured.

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. 5 smoke detectors were tested and found to be operational. There were two (2) fire extinguisher last was recharged, 10/15/2021. LPA advised the facility representative that the fire extinguisher was expired and for best practice they should get the fire extinguishers replaced. The facility caregiver states that they don’t do emergency disaster/fire drills. LPA advised facility to perform disaster/fire drills.
(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)

Page: 2 of 4

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: HOVLEY CARE LLC	FACILITY NUMBER: 336425566
	VISIT DATE: 06/01/2023

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
26
27
28
29
30
31
32

(Continuation from LIC809)

Based on the information received during this visit today in the areas reviewed, there are 1 type A deficiency 87412(d) that will be assessed with an civil penalty that are being cited per Title 22, Division 6 of The California Code of Regulations. Upon the facility tour, LPA learned that resident Mary Firmin had passed away April 12, 2023. Upon looking at the facility files and submitted SIRS, the facility has not sent in any SIRS since 2018. There was no death report for Mary Firmin. LPA and facility representative collaborated and agreed to have the 2 fire extinguisher replaced or recharged, an infection control plan in place, CPR and first aid certification current. Licensee states that carbon monoxide will bought and in the facility in 24 hours. The facility has agreed to have a plan of corrections emailed to the LPA by June 8, 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 04:52 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: HOVLEY CARE LLC	FACILITY NUMBER: 336425566
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87412(d)

This requirement is not met as evidenced by: Facility does not have any carbon monoxide alarms in the facility.
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in zero (0) carbon monoxide alarms are in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	Facility will buy a carbon monoxide and send proof to LPA.

Type A

Section Cited

CCR

87211(a)

This requirement is not met as evidenced by: No SIR for resident's death. Facility has not reported any SIR to CDSS.
	Deficient Practice Statement
1 2 3 4	During annual, LPA observed and through interview and record review, the licensee did not comply with the section cited above in not reporting to CDSS any serious incident reports, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/08/2023
	Plan of Correction
1 2 3 4	LPA will do a case management with facility.

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)

Page: 4 of 4