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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426413
Report Date: 05/20/2022
Date Signed: 05/20/2022 03:42:30 PM


Document Has Been Signed on 05/20/2022 03:42 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
, CA 92507



FACILITY NAME:APPLE GARDEN SENIORSFACILITY NUMBER:
366426413
ADMINISTRATOR:GEORGE KARKALETSISFACILITY TYPE:
740
ADDRESS:12994 RINCON RD.TELEPHONE:
(760) 240-2600
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY:6CENSUS: 3DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:George KarkaletsisTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rayshaun Nickolas conducted an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Nickolas arrived and met with Administrator, Karkaletsis. LPA Nickolas was asked to sign-in upon arrival. The administrator confirmed that there are currently no cases/exposures of COVID-19 within the facility.

During the inspection, LPA Nickolas conducted a tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPA Nickolas observed appropriate postings throughout the facility, including hand-washing etiquette, face coverings, and COVID-19 symptoms postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and less than a 30 day supply of Personal Protective Equipment (PPE). LPA observed that the facility staff were wearing face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division (CCLD) guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

LPA observed an uncovered inflatable above ground pool in the backyard partially filled with water. LPA observed appliances (refrigerator and vacuum cleaners) and other household items stored throughout the backyard.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
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 4


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
, CA 92507
FACILITY NAME: APPLE GARDEN SENIORS
FACILITY NUMBER: 366426413
VISIT DATE: 05/20/2022
NARRATIVE
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Based on observations made during today’s inspection, two deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy of this report was provided to Karkaletsis at the conclusion of the inspection.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/20/2022 03:42 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
, CA 92507


FACILITY NAME: APPLE GARDEN SENIORS
FACILITY NUMBER: 366426413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307
87307 Personal Accommodations and Services (e)

(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water, when not in active use by residents, through fencing, covering or other means.


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 allowing an inflatable above ground pool partially filled with water in the backyard. Which poses an immediate health & safety risk to persons in care.
POC Due Date: 05/21/2022
Plan of Correction
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Licensee shall remove inflatable above ground pool. Licensee shall submit proof of removal of inflatable above ground pool by the close of business of May 23, 2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 05/20/2022 03:42 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
, CA 92507


FACILITY NAME: APPLE GARDEN SENIORS
FACILITY NUMBER: 366426413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303
87303 Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 storing appliances (vacuum cleaners and a refridgerator) and other house hold items in the backyard. Which poses a potential health and safety risk to persons in care.
POC Due Date: 06/30/2022
Plan of Correction
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Licensee shall remove all appliances and household items from the backyard. Licensee shall submitt proof of Plan of Correction by June 30, 2022 by the close of business,
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4