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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426054
Report Date: 09/12/2023
Date Signed: 09/12/2023 03:35:27 PM


Document Has Been Signed on 09/12/2023 03:35 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:CALEO BAY ALZHEIMER'S SPECIAL CARE CENTERFACILITY NUMBER:
336426054
ADMINISTRATOR:WILKIN, RONDAFACILITY TYPE:
740
ADDRESS:47805 CALEO BAY DRIVETELEPHONE:
(760) 771-6100
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:66CENSUS: 51DATE:
09/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Executive Director, Maria ArriagaTIME COMPLETED:
03:33 PM
NARRATIVE
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On 9/12/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility for an unrelated matter. LPA met with Executive Director, Maria Arriaga, who was informed of the purpose of the visit. This report is to document deficiencies found.

It was found that Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) were not associated to the facility roster. LPA reviewed the staff schedule for September 2022 and found S1, S2 and S3 are working at the facility. LPA reviewed the department database and found S1, S2 and S3 are all fingerprint cleared. It was documented that S1, S2, and S3 have all worked at the facility for more than 5 days. Therefore, the facility is being cited for the three (3) staff not being associated to the facility. As of today's date, the three staff are no longer employed at the facility. A civil penalty is applied to the deficiency for the maximum amount of $500 per employee. Total civil penalties issued is $1500. Plan of correction was made with Executive Director, Maria Arriaga, and documented.

An exit interview was conducted where this report, Civil Penalty assessment LIC 421BG, LIC9099-D page, and Appeal Rights were reviewed and provided to Executive Director, Maria Arriaga.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
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 2


Document Has Been Signed on 09/12/2023 03:35 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: CALEO BAY ALZHEIMER'S SPECIAL CARE CENTER
FACILITY NUMBER: 336426054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2023
Section Cited
CCR
87355(e)(2)

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(e) All individuals subject to a criminal record review...shall prior to working...in a licensed facility:(2)Request a transfer of a criminal record clearance...This requirment was not met as evidenced by:
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The administrator stated they send the LPA a self certified statement by the POC due date stating that they have reviewed their roster and understand
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Based on record review it was found that three staff were not associated to the facility. This poses an immediate health safety or personal rights risk to residents in care.
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the process to associate staff to their facility.

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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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
LIC809 (FAS) - (06/04)
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