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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426746
Report Date: 08/30/2022
Date Signed: 08/30/2022 02:45:34 PM

Document Has Been Signed on 08/30/2022 02:45 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:PETUNIA ROYALE ASSISTED LIVING, LLCFACILITY NUMBER:
336426746
ADMINISTRATOR:FELICITAS MABBAYADFACILITY TYPE:
740
ADDRESS:74127 E. PETUNIA PLACETELEPHONE:
(760) 779-5898
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY: 6CENSUS: 3DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Vincent Cabauatan - CaregiverTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with caregiver Vincent Cabauatan and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with caregiver Vincent Cabauatan, who LPA Colvin found to be successfully incorporating the several aspects of the infection control, despite not having a Mitigation Plan on file. LPA Colvin inquired about if there was a copy at the facility for LPA Colvin to review (as there is no evidence that one has been submitted to Licensing) and the caregiver Vincent Cabauatan stated that there is not. LPA Colvin will be issuing a Technical Advisory Note for the facility not having a Mitigation Plan. LPA Colvin will not be issuing a deficiency as the Mitigation Plan request/requirement is outdated, and facilities are now being advised to submit an Infection Control Plan. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns). LPA Colvin observed the facility to not have an adequate supply of PPE, and caregiver Vincent Cabauatan was unaware of where additional PPE might be located. LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note for the facility not having a 30-day supply of PPE. LPA Colvin went over the various recommended training for facility staff with caregiver Vincent Cabauatan in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE.

LPA Colvin inquired as to if staff have been fit tested for N95 masks, and caregiver Vincent Cabauatan informed LPA Colvin that they have. LPA Colvin inquired about if the facility is screening their residents daily for COVID-19 symptoms, which includes checking their temperature. caregiver Vincent Cabauatan confirmed that residents are being screened daily.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2022
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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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: PETUNIA ROYALE ASSISTED LIVING, LLC
FACILITY NUMBER: 336426746
VISIT DATE: 08/30/2022
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 LPA Colvin observed a sign-in sheet at the front door of the facility, and confirmed that visitors and staff are being screened for symptoms prior to entering the facility, as LPA Colvin was today. LPA Colvin additionally confirmed that all facility staff are vaccinated, so the facility is not required to continue with surveillance testing weekly, and caregiver Vincent Cabauatan confirmed that both new staff and new residents must present a negative COVID-19 test prior to start of employment or residence at the facility.

Other: During LPA Colvin's inspection, LPA Colvin observed that Vincent Cabauatan and his wife Ingrid were both not on the facility's employee roster, or associated to the facility. LPA Colvin contacted two staff back at the Licensing Office to double and triple check, and both staff confirmed that while both Cabauatans have background clearance, neither is associated to any facility. LPA Colvin inquired with Vincent Cabauatan as to how long he and his wife have been working at the facility. Vincent Cabauatan claimed that today was his and his wife's first day, though they have worked here previously. LPA Colvin attempted to contact the Administrator to verify employment start date, but was unable to reach them. LPA Colvin will be citing a deficiency and issuing civil penalties in the amount of $100 per staff for one day working at the facility, for a total of $200. LPA Colvin will additionally be issuing a deficiency for not being able to access staff files.

An exit interview was conducted with caregiver Vincent Cabauatan and a copy of this report, LIC809D, LIC421BG, appeal rights, and LIC9102 TA Advisory Notes were provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
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Document Has Been Signed on 08/30/2022 02:45 PM - It Cannot Be Edited


Created By: Crystal Colvin On 08/30/2022 at 02:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PETUNIA ROYALE ASSISTED LIVING, LLC
FACILITY NUMBER: 336426746

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87355(e)(2)
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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 of 2 staff present, which poses an immediate safety risk to persons in care. LPA Colvin observbed both staff present at the facility to not be associated to the current facility, or any other facility.
POC Due Date: 08/31/2022
Plan of Correction
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Licensee agrees to remove staff Vincent & Ingrid from the schedule until they assocaite them to the facility. Licensee may self-certify to LPA Colvin once complete. Plan of Correction Date 8/31/22.
Type A
Section Cited
CCR
87412(g)
Personnel Records: (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 of 2 staff files,which poses an immediate safety risk to persons in care. LPA Colvin was unable to gain access to files for staff currently present at the facility in order to verify employement start date.
POC Due Date: 08/31/2022
Plan of Correction
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Licensee to submit Statement of Understanding regardign all staff and resident files needing to be accessible to licensing during regular business hours. Licensee to additionally submit plan to LPA Colvin for what will be done to ensure this is possible. Licensee to submit statement and plan to LPA Colvin by Plan of Correction Date of 8/31/22.
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
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022


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