336426769-6-2-2022-18-AS-MVAO-CV2Q8K-20230825115653

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426769
Report Date: 06/02/2022
Date Signed: 06/02/2022 03:36:17 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2022 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220526155536

FACILITY NAME:	FOUNTAINS AT THE CARLOTTA, THE		FACILITY NUMBER:	336426769
ADMINISTRATOR:	RONALD F. ELLENICH		FACILITY TYPE:	741
ADDRESS:	41505 CARLOTTA DR.		TELEPHONE:	(760) 346-5420
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92211
CAPACITY:	250	CENSUS: 207	DATE:	06/02/2022
		UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	Ronald Ellenich, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility has pests

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation. LPA identified himself and discussed the purpose of the visit with Administrator Ronald Ellenich (S1) who accompanied LPA on a tour of the facility.

The Department of Environmental Health conducted a visit, and found an infestation of pests. LPA further found that facility staff were not following a kitchen cleaning plan as a result of interviews with S1, Director of Maintenance Nestor Torres (S2), and Chef Marco Valencia (S3). Thus, LPA found that this allegation was SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Thus, the facility was cited. Continued on LIC9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220526155536

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: FOUNTAINS AT THE CARLOTTA, THE	FACILITY NUMBER: 336426769
	VISIT DATE: 06/02/2022

NARRATIVE

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LPA collected pertinent documents in relation to the allegation.

LPA also found that the facility did not report the incident to licensing via written document per Title 22. Deficiency cited.

At the time of visit, the facility was cleared via the Department of Environmental Health as well as through the Department of Public Health.

An exit interview was conducted, and a copy of this report was discussed with and provided to Mr. Ellenich along with copies of the LIC811, LIC9099-D, and Appeal Rights.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220526155536

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: FOUNTAINS AT THE CARLOTTA, THE	FACILITY NUMBER: 336426769
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/16/2022 Section Cited CCR 87211(a)(D)	1 2 3 4 5 6 7	REPORTING REQUIREMENTS: (a) Each licensee shall..licensing agency..(D) Any incident which threatens..safety or health of any resident..This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to review the regulation, and self-certify they understand the regulation to LPA via email by POC date.
	8 9 10 11 12 13 14	Based on LPA interview of S1, and review of record, LPA found that the incident was not reported via written document per regulation. This poses a potential risk to residents in care.	8 9 10 11 12 13 14
Type B 06/16/2022 Section Cited CCR 87555(b)(27)	1 2 3 4 5 6 7	GENERAL FOOD SERVICE REQUIREMENTS:(b) The following food service..(27)All kitchen areas..and free of..insects. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator gave LPA updated cleaning inspection sheet at the time of visit, POC cleared.
	8 9 10 11 12 13 14	Based on LPA's interview of S1, the Licensee did not follow the cleaning plan as evidenced by the presence of roaches. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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