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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800168
Report Date: 03/06/2024
Date Signed: 03/06/2024 11:46:44 AM

Document Has Been Signed on 03/06/2024 11:46 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:DULCE VILLA IIFACILITY NUMBER:
331800168
ADMINISTRATOR:MODY, NIKULFACILITY TYPE:
740
ADDRESS:66171 S AGUA DULCE DRTELEPHONE:
(760) 251-4606
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY: 6CENSUS: 5DATE:
03/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lorena Guillan - Facility ManagerTIME COMPLETED:
12:00 PM
NARRATIVE
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During Licensing Program Analyst (LPA) Crystal Colvin's inspection at the facility to conduct an inspection. During this inspection, LPA Colvin observed the following violations which needed to be addressed:

Physical Plant: During the inspection, LPA Colvin observed a cabinet near the washing facilities containing cleaning supplies, including bed bug spray, to be unlocked. Deficiency cited. LPA Colvin additionally observed a mattress in the backyard to be obstructing a exit from the building (sliding glass door). Deficiency cited. This is a violation of the facility's fire clearance and warrants an immediate civil penalty in the amount of $500, which LPA Colvin will be issuing today. LPA Colvin was unable to access a copy of the facility's Plan of Operation, as it was located in a locked staff room which was inaccessible to LPA Colvin during today's inspection (though the Administrator was able to email LPA Colvin what she needed). Licensing is to have access to all areas of the facility at any time, and inability to inspect any room/area results in a deficiency and immediate civil penalty of $500, which LPA Colvin will be assessing today.

Personal Rights: During record review and interviews, it was revealed that on some occasions (including 2/11/24) that Resident One (R1) will request to make a call to family members and is denied by staff due to family requesting that the resident not call until at least 10am. LPA Colvin inquired as to if there is any documentation of this request from family, and Facility Manager Lorena Guillan denied any such records. LPA Colvin additionally reviewed R1's most recent Individual Program Plan (IPP) and did not observe any mention of this behavior or of it being deemed as inappropriate and the facility staff needing to address it in a specific way. Therefore, denying R1 from making a call when requesting to is a violation of R1's personal rights. Deficiency cited. LPA Colvin learned through interviews that R1 has been sleeping on a mattress in the living room for the last week while R1's room is being treated for bed bugs. LPA Colvin additionally observed in the daily notes for R1 that R1 has not been able to take a nap during the day, due to staff moving the mattress during the day and R1 not having a location to sleep. Deficiency cited.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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: DULCE VILLA II
FACILITY NUMBER: 331800168
VISIT DATE: 03/06/2024
NARRATIVE
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Based on observations made by LPA Colvin, the facility was cited deficiencies and assessed civil penalties in the amount of $1,000. An exit interview was conducted with Facility Manager Lorena Guillan and Administrator Trupti Mody (via telephone) and a copy of this report, LIC809Ds, LIC421IMs, appeal rights, and LIC9098 Proof of Corrections, was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/06/2024 11:46 AM - It Cannot Be Edited


Created By: Crystal Colvin On 03/06/2024 at 11:04 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DULCE VILLA II
FACILITY NUMBER: 331800168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/07/2024
Section Cited
CCR
87307(d)(6)

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Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met by:
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Licensee agrees to remove mattress blocking doorway and provide LPA Colvin with photographic proof of correction. Plan of Correction due by 3/7/24.
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Based on observations, the Licensee did not comply with the above regulation with one doorway (back sliding glass door to bedroom). This is an immediate safety risk to residents in care.
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Request Denied
Type A
03/07/2024
Section Cited
CCR87755(a)

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Inspection Authority of the Licensing Agency: (a) Any duly authorized officer, employee or agent of the licensing agency may...inspect the entire premise...with or without advance notice. This requirement was not met by:
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Licensee agrees to formulate plan to ensure Licensing has access to all areas of facility at all times. Licensee to provide plan to LPA Colvin by Plan of Correction date of 3/7/24.
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Based on interview and observation, the Licensee did not comply with the above regulation with one room (staff room). This is an immediate safety risk for residents in care.
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2024 11:46 AM - It Cannot Be Edited


Created By: Crystal Colvin On 03/06/2024 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DULCE VILLA II
FACILITY NUMBER: 331800168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/07/2024
Section Cited
CCR
87705(f)(2)

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Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (2)...toxic substances such as...cleaning supplies and disinfectants. This requirement was not met by:
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Licensee agrees to have staff lock the cabinet immediately as well as conduct staff training or hold house meeting on locking hazardous items at all times. Licensee to provide LPA Colvin with proof of training or meeting by Plan of Correction date of 3/7/24.
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Based on observation, the Licensee did not comply with the above regulation with one area of the facility (cabinet by laundry machines). This poses an immediate health and safety risk to residents in care.
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Deficiency Dismissed
Type A
03/07/2024
Section Cited
CCR87307(a)(a)(B)

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Personal Accommodations and Services: (a) ...The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident...
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Licensee agrees to cease having R1 sleep in the living room and come up with other accomodations. Licensee to provide LPA Colvin with update on where R1 will be sleeping. Licensee to review regulation and self-certify understanding and that correction
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This requirement was not met by: Based on interview and observations, the Licensee did not comply with one room of the facility (living room). LPA Colvin learned that R1 has been sleeping in the living room. This is an immediate personal rights violation of R1.
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has been made. Due by Plan of Correction date of 3/7/24.
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2024 11:46 AM - It Cannot Be Edited


Created By: Crystal Colvin On 03/06/2024 at 11:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DULCE VILLA II
FACILITY NUMBER: 331800168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/07/2024
Section Cited
CCR
87468.1(a)(14)

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Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls.... This was not met by:
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Licensee agrees to train staff on resident rights. Licensee may consult with Inland Regional Center on this behavior if they would like to be able to address it. Licensee to provide LPA Colvin with proof of staff training by Plan of Correction date of 3/7/24.
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Based on record review and interviews, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin learned that R1 is sometimes denied from making telephone calls to family due to time of day (8am) this is an immediate personal rights violation.
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
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