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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426505
Report Date: 06/22/2022
Date Signed: 06/22/2022 12:12:43 PM


Document Has Been Signed on 06/22/2022 12:12 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:STONEWALL GARDENS ASSISTED LIVINGFACILITY NUMBER:
336426505
ADMINISTRATOR:BOEDDEKER, ALLENFACILITY TYPE:
740
ADDRESS:2150 N PALM CANYON DRTELEPHONE:
(760) 548-0970
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:35CENSUS: 23DATE:
06/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:James Dunning - AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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On this date, Licensing Program Analyst (LPA) Crystal Colvin made an unannounced visit to the facility to investigate a complaint #18-AS-20220621091121. During today's inspection, LPA Colvin observed the following deficiency, which was reviewed with Administrator James Dunning:

In LPA Colvin's review of the facility's file prior to coming out to conduct the inspection, LPA Colvin observed that the facility has overdue licensing fees. These fees consist of annual fees for the year 2021, as well as subsequent late fees for that year. As of today's inspection, the Licensee owes $1,857.00 in overdue licensing fees. Deficiency cited. No other health and safety concerns observed during today's inspection.

An exit interview was conducted with Administrator James Dunning, and a copy of this report, LIC 809D, and appeal rights was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
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 06/22/2022 12:12 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: STONEWALL GARDENS ASSISTED LIVING
FACILITY NUMBER: 336426505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2022
Section Cited

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Fees for license or applications; use of revenues; collected; denial or forfeiture: (e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement was not met by:
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Based on record review, the Licensee did not comply with the above Health & Safety Code with licensing fees ($1,875.00 total). LPA Colvin observed that the facility past due licensing fees for annual fees as well as late fees for 2021. This is an immediate safety risk to all residents as license may be revoked.
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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) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
LIC809 (FAS) - (06/04)
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