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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426054
Report Date: 07/24/2024
Date Signed: 07/24/2024 05:20:52 PM


Document Has Been Signed on 07/24/2024 05:20 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:MARIA ARRIAGAFACILITY TYPE:
740
ADDRESS:47805 CALEO BAY DRIVETELEPHONE:
(760) 771-6100
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:66CENSUS: 44DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Maria Arriaga, AdministratorTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the Administrator with LPA identification. At the time of the visit there was eighteen (18) staff and forty-four (44) residents present. The facility has a dementia program and approval for locked perimeters with an alarm and signal system. The facility does not have any bodies of water and no firearms on premises. The facility is approved for 20 hospice residents; currently the facility has 14 residents receiving hospice services.

Resident record review began- Ten (10) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 109.0 degrees F. Laundry facilities and a locked area is present for storing laundry soap and other chemicals in a separate area. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location.



(Continued on page 2)
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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 3


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
VISIT DATE: 07/24/2024
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Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized.

LPA began review of employee records- Ten (10) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application-2 missing, health screening-7 missing and TB test results-5 missing, criminal record statement-2 missing, employee rights-9 missing, training verification and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current. Information was provided regarding fingerprint clearances of employees and further review is needed at this time.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 09/25/2023. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 07/18/2024.

LPA allocated time to prepare this report for delivery.

Based on the information received during this visit today, two (2) deficiencies is being cited per Title 22, Division 6 of The California Code of Regulations.

This report, LIC809D, LIC811 and Appeal Rights was reviewed with and a copy provided to the facility representative.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/24/2024 05:20 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: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in employee rights for S1, S2, S3, S4, S5, S7, S8, S9, S10, criminal record statement for S1, S6, personnel record or job appliation for S3, S9 not observed in personnel files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2024
Plan of Correction
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Licensee will ensure staff will complete documents and maintain a copy in file and email copies to LPA by POC due date.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in S1,S2, S3, S4, S5, S6, S7 did not have a health screening in their personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2024
Plan of Correction
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Licensee will ensure staff 1-7 obtain a health screening and maintain a copy in their personnel file and will email copies to LPA by POC due date.
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 HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3