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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880895
Report Date: 09/02/2021
Date Signed: 09/02/2021 04:41:57 PM

Document Has Been Signed on 09/02/2021 04:41 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
RIVERSIDE, CA 92507
FACILITY NAME:ATTENTIVE MANOR IIFACILITY NUMBER:
331880895
ADMINISTRATOR:PECK, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:31221 EL TORO RDTELEPHONE:
(760) 620-5915
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 6CENSUS: 4DATE:
09/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Chris Peck - AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of investigating a complaint (#18-AS-20210824111213). During LPA Colvin's inspection, LPA Colvin observed additional items that needed to be addressed with the Administrator. Below is a summary of what was observed:
  • Unassoicated Staff - LPA Colvin observed that two staff members (S1 & S2) are working at the facility but are not associated. LPA Colvin was able to confirm background clearance for both staff, but in review of their files at the facility LPA Colvin did not locate a clearance transfer request to the facility, which is required for the staff to be associated. A facility must have submitted a transfer request for staff with background clearance prior to them working in the facility. Deficiency cited. This deficiency comes with a civil penalty in the amount of $100 per day, per staff, for a maximum of 5 days. Since both staff have worked at the facility for longer than 5 days, the maximum penalty of $500 per staff ($1,000 total) will be assessed.

  • Locked Perimeter - LPA Colvin observed that the facility's front and side gate both have an electronic lock which requires a security code to unlock. LPA Colvin reviewed the facility's application and fire clearance and observed that the facility has not been approved for a locked perimeter. LPA Colvin additionally contacted the Cathedral City Fire Department and confirmed that the Fire Marshall did not approve the locked perimeter. Deficiency cited. A violation of a facility's fire clearance comes with an immediate civil penalty in the amount of $500, which will be assessed today. Licensee requested LPA Colvin to submit request to Fire Department for inspection for approval for delayed egress .

  • Resident Funds - LPA Colvin observed that the facility is holding on to resident funds (average of $200 for each resident). LPA Colvin reviewed the facility's application for license and confirmed that it was stated to Licensing that they would not handle resident funds. Deficiency cited.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ATTENTIVE MANOR II
FACILITY NUMBER: 331880895
VISIT DATE: 09/02/2021
NARRATIVE
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    Additionally, LPA Colvin confirmed with the Licensee that the facility does not have a surety bond, which would protect clients' money in the event of a theft. Deficiency cited. Lastly, in review of a resident's file (R1) in relation to a complaint, LPA Colvin observed that there is no accounting ledger for the resident's money. LPA Colvin inquired with the Licensee about this, and the Licensee stated that the funds are kept in an envelope along with receipts for purchases. No other accounting ledger is utilized to itemize expenses to ensure an accurate accounting of the funds held for the resident by the facility. Deficiency cited. Lastly, LPA Colvin learned in an interview with the Licensee and Administrator that R1's funds of $200 was returned to R1's Power of Attorney (POA) with $100 taken out, in order to account for repairs needed on a toilet used by R1. Title 22 Regulations state that a facility cannot use resident's personal funds (such as R1's $200) for expenses or as a deposit. Deficiency cited.
  • Reporting Requirements - LPA Colvin observed that though R1 went to the hospital on numerous occasions for emergency services, and was even admitted for several days on at least one occurance, the facility never submitted an Special Incident Reports (SIRs) to Community Care Licensing (CCL). Facilities are required to report to CCL any event or occurrence which may pose a risk to a resident's health or safety. Deficiency cited.


Due to observations made by LPA Colvin, the facility was cited and civil penalties in the amount of $1,500 were issued,

An exit interview was conducted where this report and appeal rights were discussed. A copy of this report, LIC809D, LIC421BG, LIC421IM, and appeal rights was provided to Administrator Chris Peck during the exit interview.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/02/2021 04:41 PM - It Cannot Be Edited


Created By: Crystal Colvin On 09/02/2021 at 03:23 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: ATTENTIVE MANOR II
FACILITY NUMBER: 331880895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2021
Section Cited
CCR
87355(e)(2)

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Criminal Record Clearance: (e) All individuals ....pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified... This requirement was not met as evidenced by:
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Licensee agrees to have S1 & S2 associated to the facility prior to them working their next shift. Licensee may submit transfer request online via Guardian system, or to the Riverside office in person. Proof of submission due by Plan of Correction date of 9/3/21.
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Based on record review, the Licensee did not comply with the above regulation with two staff (S1 & S2). LPA Colvin observed that S1 & S2 work at the facility but have not been associated. This is an immediate safety risk to all residents in care.
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Type A
09/03/2021
Section Cited
CCR87705(l(2)

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Care of Persons with Dementia: (l) The following initial and continuing requirements shall be met for the licensee to lock...perimeter fence gates:(2) The licensee shall ensure that the fire clearance includes approval of...locked perimeter fence gates. This requirement was not met as evidenced by:
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Licensee agrees to have locked perimeter uninstalled until Licensee obtains both approval from CCL and Fire Department to utilize locked perimeter. LPA Colvin to submit LIC850 to Fire Department for evaluation of approval for delayed egress. Licensee to self-certify to LPA Colvin that locks have been disabled.
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Based on record review and interview, the Licensee did not comply with the above regulation with two gates. LPA Colvin observed the front & side gates to have electronic locks. LPA Colvin confirmed with Fire Department that locked perimeter was not approved. This is an immediate safety risk.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/02/2021 04:41 PM - It Cannot Be Edited


Created By: Crystal Colvin On 09/02/2021 at 03:33 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: ATTENTIVE MANOR II
FACILITY NUMBER: 331880895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2021
Section Cited
CCR
87216(d)

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Bonding: (d) No licensee shall either handle money of a resident or handle amounts greater than those stated in the affidavit submitted by him or for which his bond is on file without first notifying the licensing agency and filing a new or revised bond... This requirement was not met by:
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Licensee to submit a new Affidavit to CCL, or to cease holding money for residents. Affidavit or statement confirming cease of holding resident funds to be submitted to LPA Colvin by plan of correction date of 9/16/21.
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Based on interviews and record review, the Licensee did not comply with the above regulation with all residents. LPA Colvin observed the facility holds petty cash for all residents, but has an affidavit on file with CCL that they will not handle resident funds. This is a potential personal rights violation.
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Type B
09/16/2021
Section Cited
CCR87216(a)

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Bonding: (a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. This requirement was not met by
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Licensee to obtain and submit a copy of their Surety Bond (as noted in regulation section 87216) to CCL, or to cease holding money for residents. Surety Bond or statement confirming cease of holding resident funds to be submitted to LPA Colvin by plan of correction date of 9/16/21.
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Based on interviews and record review, the Licensee did not comply with the above regulation with all residents. LPA Colvin observed the facility holds petty cash for all residents but does not have a Surety Bond to cover these funds. This is a potential personal rights risk to all residents.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/02/2021 04:41 PM - It Cannot Be Edited


Created By: Crystal Colvin On 09/02/2021 at 03:38 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: ATTENTIVE MANOR II
FACILITY NUMBER: 331880895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2021
Section Cited
CCR
87217(g)(1)

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Safeguards for Resident Cash...:(g) Each licensee shall maintain adequate safeguards and accurate records of cash resources...including...: (1) Records...shall include a ledger accounting (columns for income, disbursements and balance) for each resident... This requirement was not met by:
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Licensee agrees to maintain an accounting log for all resident money kept by the facility. Licensee to self-certify to LPA Colvin confirmation of this as well as provide LPA Colvin with a copy of an accoutning ledger for each resident or statement confirming ceasing handling resident funds.
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Based on interview and record review, the Licensee did not comply with the above regulation with all residents. LPA Colvin observed that the Licensee did not maintain a ledger for resident funds, only receipts. This is a potential personal rights violation for all residents.
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Plan of Correction due 9/16/21.
Type B
09/16/2021
Section Cited
CCR87507(g)(3)(C)(4)

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Admission Agreements: (g) Admission agreements shall specify...:(3) Payment provisions, including...: (C) Any fee that is charged...after admission... 4.A licensee shall not require, request, or accept any funds...that constitutes a deposit against any possible damages by the resident. This was not met by:
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Licensee to refund $100 to R1's POA and provide proof of refund to LPA Colvin as well as submit Statement of Understanding to LPA Colvin that resident funds ("petty cash") shall not be used as security deposit. Plan of Correction due 9/16/21.
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Based on interviews, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin learned that R1's POA was only provided $100 of the $200 funds given to the facility for R1, due to damages hte facility charged back to R1. This was a potential 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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 09/02/2021 04:41 PM - It Cannot Be Edited


Created By: Crystal Colvin On 09/02/2021 at 03:47 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: ATTENTIVE MANOR II
FACILITY NUMBER: 331880895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2021
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports...including...: (1) A written report shall be submitted to the licensing agency within seven days of the occurrence of any of the events...(D) Any incident which threatens the welfare, safety or health of any resident...
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Licensee agrees to review Regulation Section 87211 in it's entirety and self-certify to LPA Colvin once complete. Self-certification to also include Statement of Understanding and confirmation to abide by Reporting Requirements. Plan of Correction due by 9/16/21.
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This requirement was not met by: Based on interviews and record review, the Licensee did not comply with the above regulation with one resident. LPA Colvin observe R1 did not have any incident reports despite numerous hospital stays. This was a potential safety risk for R1.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


LIC809 (FAS) - (06/04)
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