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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426470
Report Date: 10/31/2023
Date Signed: 10/31/2023 09:24:32 AM


Document Has Been Signed on 10/31/2023 09:24 AM - 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:ATTENTIVE MANORFACILITY NUMBER:
336426470
ADMINISTRATOR:MATTHEW SIEGELFACILITY TYPE:
740
ADDRESS:66-338 FOURTH ST.TELEPHONE:
(760) 251-4330
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY:0CENSUS: 0DATE:
10/31/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:LICENSEE, MATTHEW SIEGELTIME COMPLETED:
09:30 AM
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On October 31,2023, Licensing Program Analyst (LPA), Venus Mixson conducted a case management visit with the Licensee. The visit was pertaining to another matter that was being investigated.

LPA Mixson introduced herself and explained the purpose of the meeting. LPA Mixson explained the information obtained as a direct result of an investigation that took place prior to the listed facility closing. The information was obtained from a police reported that was dated 09/02/2020. The information stated the Desert Hot Springs Police Department was contacted due to possible elder abuse. The resident in question was Resident 1 (R1), a 90 year old male who resided in the listed facility as a resident. The information obtained stated the Officer conducted a walk through the facility and the home appeared well kempt, had plenty of food, and spoke to R1. The information stated the resident sustained bruising to both forearms and small scratched to his left forearm, and pinky finger. The information stated the resident did not appear to be in immediate danger and the report was closed, and the Officer was cleared from the event.

As a direct result of the physical nature of the argument the Department has determined to cite the listed facility for violation of a residents personal rights.
An exit interview was conducted with the Licensee and a copy of this report, along with the Appeal Rights, and the Licensee, Matthew Siegel.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
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 10/31/2023 09:24 AM - 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: ATTENTIVE MANOR
FACILITY NUMBER: 336426470

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2023
Section Cited
CCR
87468(a)(3)

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PERSONAL RIGHTS
Each resident shall be free from corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature. This regulation was not met as a result of
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Effective immediately, no staff shall violate any resident's personal rights. Licensee will provide a plan of Statement that no residents personal rights will be violated.
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Based on record reviews and interviews the resident was not free from corporal or unusual punishment, humiliation, intimidation, or mental abuse. This poses a potential personal rights, health or safety risk to residents 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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
LIC809 (FAS) - (06/04)
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