336411977-8-5-2024-18-AS-SJEN-D7UPNW-20240805112837

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336411977
Report Date: 08/05/2024
Date Signed: 08/05/2024 11:28:57 AM

Document Has Been Signed on 08/05/2024 11:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	FOUR SEASONS ELDERLY CARE HOME, INC.		FACILITY NUMBER:	336411977
ADMINISTRATOR:	VALDOVINO, TERESITA		FACILITY TYPE:	740
ADDRESS:	81-399 AVENIDA COYOTE		TELEPHONE:	(760) 702-3878
CITY:	INDIO	STATE: CA	ZIP CODE:	92201
CAPACITY:	6	CENSUS: 6	DATE:	08/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Jacqueline Omane, care giver		TIME COMPLETED:	11:40 AM

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Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. LPA was granted entry and met with staff, Jacqueline Omana, caregiver who was informed of the purpose of the visit. At the time of the visit there were 2 staffs and 6 clients present.

The facility is a single story home with 4 bedrooms and 2 bathrooms with attached garage. There is a swimming pool with locked gate and fences that are in compliance. There is no known firearms or other dangerous weapons stored at the facility. The clients served are adults 60 and up. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted staff and client interviews. LPA observed the following:

The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed seven (7) staff files. All staffs have criminal clearance and updated training along with CPR/First Aid Certification. Six(6) client files were reviewed and possessed all required paperwork.

LPA observed the client bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke and carbon monoxide detectors were operational, and the hot water temperature was 109.8 degrees F.

continued on LIC809C...

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FOUR SEASONS ELDERLY CARE HOME, INC.	FACILITY NUMBER: 336411977
	VISIT DATE: 08/05/2024

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LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Adequate staffs are present for the supervision of clients during the visit. LPA also reviewed the staff schedule showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate.

All client medications were locked in a cabinet located in the kitchen. LPA reviewed medications for three(3) clients and found all medication listed on MARs and all required labeling was found to be in place.

LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility performs quarterly fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted where a copy of this report was provided to administrator, Teresita Valdovino.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024

LIC809 (FAS) - (06/04)

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