336425954-9-19-2024-18-AS-SJEN-D99V25-20240919160235

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425954
Report Date: 09/19/2024
Date Signed: 09/19/2024 04:02:44 PM

Document Has Been Signed on 09/19/2024 04:02 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CARMIE CARES HOME FOR THE ELDERLY 1		FACILITY NUMBER:	336425954
ADMINISTRATOR:	JAY SESE		FACILITY TYPE:	740
ADDRESS:	32220 SHIFTING SANDS TRAIL		TELEPHONE:	(760) 656-1177
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY:	6	CENSUS: 6	DATE:	09/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Carmelita Sese, caregiver		TIME COMPLETED:	04:15 PM

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Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Carmelita Sese, caregiver, and informed her of the purpose of the visit. At the time of the visit, there were (2) staff members and (6) residents present.

Facility Overview: The facility is a one-story home with (5) bedrooms and (3) bathrooms, including an attached garage. There are no pools or known firearms on the premises.

Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 120°F.

Food Service: The facility’s kitchen counter top was cluttered with many items that were not related to food preparation. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.

Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator's certificate has been expired as of 8-6-2024. Citation is issued.

Continued on LIC809-C.....

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CARMIE CARES HOME FOR THE ELDERLY 1	FACILITY NUMBER: 336425954
	VISIT DATE: 09/19/2024

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Record Review and Resident/Staff Files: LPA reviewed files for one (1) staff member, confirming criminal clearances, updated training, and CPR/First Aid certification. Four resident files were reviewed and contained all required documentation.

Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for four residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for.

One (1) deficiency was cited during the visit. An exit interview was conducted, during which this report was reviewed and provided along with LIC809-D and appeals rights.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2024 04:02 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CARMIE CARES HOME FOR THE ELDERLY 1	FACILITY NUMBER: 336425954
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one out of one which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2024
	Plan of Correction
1 2 3 4	Administrator, Jay Sese, will submit his proof of completion of required continuing classes to the Department by POC date of 10-18-2024 by 5:00 pm.

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: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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