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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424971
Report Date: 11/19/2024
Date Signed: 11/19/2024 02:41:06 PM

Document Has Been Signed on 11/19/2024 02:41 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HIGH DESERT RESIDENTIAL CARE, LLCFACILITY NUMBER:
366424971
ADMINISTRATOR/
DIRECTOR:		YIP, TERESAFACILITY TYPE:
740
ADDRESS:8980 JOSHUA LANETELEPHONE:
(760) 853-0464
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY: 12TOTAL ENROLLED CHILDREN: 0CENSUS: 10DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Administrator Teresa YipTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Teresa Yip, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (12), a current census of (10). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has a swimming pool that is gated and locked inaccessible to residents in care. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities The facility is equipped with operating smoke detectors/carbon monoxide alarms, laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in two (2) bathrooms measured between 107 to 109 degrees F. Five (5) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, menu, facility sketch, emergency telephone numbers, CCLD complaint poster, and Ombudsman poster.

Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps and chemicals were kept locked and inaccessible to residents in care.

Continuation on LIC – 809C:
Karen ClemonsTELEPHONE: (951) 836-2784
Sarina RamirezTELEPHONE: (951) 248-0307
DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 11/19/2024 02:41 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: HIGH DESERT RESIDENTIAL CARE, LLC
FACILITY NUMBER: 366424971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by Staff had an expired CPR certificate which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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Licensee has agreed to send LPA proof of CPR training for Staff #1 by POC due date
Section Cited
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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not reassociating Staff #2 to Guardian which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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Licensee has agreed to send LPA proof of association for staff #2 by POC due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen ClemonsTELEPHONE: (951) 836-2784
Sarina RamirezTELEPHONE: (951) 248-0307

DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HIGH DESERT RESIDENTIAL CARE, LLC
FACILITY NUMBER: 366424971
VISIT DATE: 11/19/2024
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Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff #1 had an expired CPR certificate, citation will be issued.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet.

Record Review: Four (4) Staff files reviewed were observed to be incomplete, staff #2 was not reassociated to guardian; citation will be issued. Three (3) Resident files reviewed were observed to be complete.

Based on observations and record review deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report along with LIC 809D, and appeal rights was discussed and provided to Administrator Teresa Yip.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina RamirezTELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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