336426054-7-17-2023-18-AS-SMAZ-CTTR3M-20230717124008

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426054
Report Date: 07/17/2023
Date Signed: 07/17/2023 12:40:15 PM

Document Has Been Signed on 07/17/2023 12:40 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:	CALEO BAY ALZHEIMER'S SPECIAL CARE CENTER		FACILITY NUMBER:	336426054
ADMINISTRATOR:	WILKIN, RONDA		FACILITY TYPE:	740
ADDRESS:	47805 CALEO BAY DRIVE		TELEPHONE:	(760) 771-6100
CITY:	LA QUINTA	STATE: CA	ZIP CODE:	92253
CAPACITY:	66	CENSUS: 52	DATE:	07/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Maria Arriaga - Executive Director		TIME COMPLETED:	12:50 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) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Executive Director, Maria Arriage, who was informed of the purpose of the visit. At the time of the visit there was seventeen (17) staff and fifty-two (52) 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 does not allow firearms on premises. The facility is approved for 20 hospice residents; currently the facility has 15 residents receiving hospice services. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following: Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. Physical Plant: LPA observed the resident bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The smoke detector and carbon monoxide was operational, and the hot water temperature 115.9F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Facility receives delivery shipments twice a week and has emergency food prepared. Facility has menus and alternative menus posted for residents.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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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Document Has Been Signed on 07/17/2023 12:40 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: CALEO BAY ALZHEIMER'S SPECIAL CARE CENTER	FACILITY NUMBER: 336426054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in having five (5) staff members associated with this facility during the time of LPA's visit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2023
	Plan of Correction
1 2 3 4	Licensee will ensure employees are associated before being allowed to work at this facility based on Title 22 regulations. Executive Director will associate employees by the agreed POC date so they are able to work at facility. Licensee will provide a statement of understanding of the title 22 regulations along with proof of association to LPA.

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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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: CALEO BAY ALZHEIMER'S SPECIAL CARE CENTER	FACILITY NUMBER: 336426054
	VISIT DATE: 07/17/2023

NARRATIVE

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Care & Supervision/Administration: Adequate staff are present for the supervision of residents during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator, possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed five (5) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. LPA observed five (5) staff not associated with this facility when looking over staff schedule. LPA informed Executive Director Maria and a civil penalty and plan of correction will be issued. Five (5) resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: The facility has a medication room, which is kept locked. The dispensing of residents medications is documented on an electronic MAR log and the medication appears to be locked and stored appropriately. The medication room is stocked with first aid supplies as required by Title 22 regulations.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where a copy of this report was provided to Executive Director Maria Arriaga.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC809 (FAS) - (06/04)

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