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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800168
Report Date: 05/09/2024
Date Signed: 05/09/2024 01:39:39 PM

Document Has Been Signed on 05/09/2024 01:39 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:DULCE VILLA IIFACILITY NUMBER:
331800168
ADMINISTRATOR/
DIRECTOR:		MODY, NIKULFACILITY TYPE:
740
ADDRESS:66171 S AGUA DULCE DRTELEPHONE:
(760) 251-4606
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY: 6CENSUS: 4DATE:
05/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Trupi Mody, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Manager (LPM) Tricia Danielson and Licensing Program Analyst (LPA) Janette Romero arrived unannounced to the facility to conduct a case management visit in conjunction with a case management- deficiencies visit conducted on 3/6/2024. LPM and LPA met with Licensee Trupi Mody and explained the purpose of the visit.

On 3/6/2024, a case management- deficiencies visit was conducted with Lorena Guillan - Facility Manager and LIC809D dated 3/6/2024 was issued. The LIC809D documented a deficiency for Section 87307(d)(6)- Personal Accommodations and Services. On appeal, this deficiency was dismissed as the incorrect statute was cited.
The purpose of today's visit is to issue a citation with the correct statute. During today's visit, LPM, LPA and Mody discussed and developed a plan of correction for the deficiency. The attached LIC809D documents the correctly cited deficiency.

An exit interview was conducted and a copy of this report was provided along Appeal Rights.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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Document Has Been Signed on 05/09/2024 01:39 PM - It Cannot Be Edited


Created By: Tricia Danielson On 05/08/2024 at 08:59 PM
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: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
87203

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Fire Safety- All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by:
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LPM observed the mattress has been removed. The POC has therefore been met and the deficiency was cleared during today's visit.
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Based on observations, the Licensee did not comply with the above regulation due to a mattress blocking a back sliding glass exit door from a bedroom. This is a potential health, safety, and personal rights risk to 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:Reyna Lacey
LICENSING EVALUATOR NAME:Tricia Danielson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
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