331800001-10-10-2024-18-AS-AZEO-D9WUAY-20241010152530

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800001
Report Date: 10/10/2024
Date Signed: 10/10/2024 03:25:47 PM

Document Has Been Signed on 10/10/2024 03:25 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	TERRA LAGO ASSISTED LIVING		FACILITY NUMBER:	331800001
ADMINISTRATOR/ DIRECTOR:	SAIS CHOUDRY		FACILITY TYPE:	740
ADDRESS:	84701 VELIERO CT		TELEPHONE:	(760) 342-3627
CITY:	INDIO	STATE: CA	ZIP CODE:	92203
CAPACITY: 6		CENSUS: 5	DATE:	10/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Hussain Abid		TIME VISIT/ INSPECTION COMPLETED:	03:35 PM

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Licensing Program Analysts (LPAs) Abdoulaye Zerbo and Armando Perez conducted an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPAs were greeted by Abid Hussain, notified of the purpose for the visit and were allowed to enter the facility to conduct the inspection. Facility Overview: The facility is a single story building with 4 bedrooms and 3 bathrooms. There is no gated pool and there are no firearms on the premises.

Infection Control: LPAs observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair.LPAs observed a reclining sofa being used as a bed for the resident. A physician's order from the resident's doctor was provided allowing patient to sleep in recliner The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in kitchen cabinet and inaccessible to residents. The smoke detector and carbon monoxide detector were hard wired together and operational. LPAs observed fire extinguishers to be in compliance with the department requirements and with and expiration date of 12/31/2025. LPAs observed the hot water temperature to meet requirements at 106.7°F.

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.

Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of March 8^th, 2025.

Continued on LIC809-C.....

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

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: TERRA LAGO ASSISTED LIVING	FACILITY NUMBER: 331800001
	VISIT DATE: 10/10/2024

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Record Review and Resident/Staff Files: LPAs reviewed files for four staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Five residents' files were reviewed and contained all required documentation. LPA's observed Staff, resident files, first aid kit, PPE's were store in closet room and emergency food and water stored in the garage.

Health-Related Services/Incidental Medical Services: All residents' medications were securely locked located in the living room area. LPAs reviewed medications for five residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for.

Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 10-2-2024, which met department requirements. All facility exits were clear of obstructions.

No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Abid Hussain

LPAs took lunch from 12:30PM to 01:05PM

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC809 (FAS) - (06/04)

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