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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426054
Report Date: 09/30/2021
Date Signed: 09/30/2021 01:58:47 PM

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: 57DATE:
09/30/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Sheila Fike, Executive DirectorTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deborah Mullen conducted an unannounced case management visit. LPA met with Sheila Fike, Executive Director. The purpose of the visit was to follow up on information obtained during the Department’s investigation of complaint control # 18-AS-20191104153922.

On 10/26/2019, resident 1 (R1) was found sitting near the nurse station at approximately 0600. R1 had injuries to the face,eye and lip. R1 was provided first aid treatment, however, 911 was not called for approximately 1 hour 45 minutes after first being observed with injuries. A review of R1s medical records revealed R1 sustained a superficial laceration of the lip with minimal swelling, multiple superficial skin tears in the lower extremities, multiple bruises, closed head contusion, closed fracture of multiple ribs of rights side, initial encounter and hemopneumothorax on right side.

Based on information obtained, the Department has concluded that staff failed to obtain emergency medical treatment for R1 in a timely manner. In accordance with California Code of Regulations, Title 22, Chapter 6 a citation is being issued as detailed on the attached LIC 809D.

An exit interview was conducted and a copy of this report, along with appeal rights, were reviewed with and provided to Sheila Fike.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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
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: 09/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2021
Section Cited

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Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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This requirement was not being met as evidenced by: R1 was first observed at approximately 0600 with injuries to the face, eye and lip. Staff failed to call 911 for emergency medical treatment until approximately 0745. This posed an immediate health and safety risk to resident in care.

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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: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2021
LIC809 (FAS) - (06/04)
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