331880895-7-14-2023-18-AS-SMAZ-CTQS9E-20230714134036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880895
Report Date: 07/14/2023
Date Signed: 07/14/2023 01:40:49 PM

Document Has Been Signed on 07/14/2023 01:40 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ATTENTIVE MANOR II		FACILITY NUMBER:	331880895
ADMINISTRATOR:	PECK, CHRISTOPHER		FACILITY TYPE:	740
ADDRESS:	31221 EL TORO RD		TELEPHONE:	(760) 620-5915
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY: 6		CENSUS: 6	DATE:	07/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Matthew Siegel - Licensee		TIME COMPLETED:	01:55 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Licensee, Matthew Siegel, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and (5) residents present.

The facility is a one-story home with six (6) bedrooms and four (4) bathrooms with attached garage. The residents served are elderly adults 65 years of age and older. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following:

Infection Control: 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 staff records and found that all staff had infection control training.

Physical Plant: LPA observed the client bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for residents. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide was operational, and the hot water temperature 118.2 F.

Food Service: 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.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATTENTIVE MANOR II	FACILITY NUMBER: 331880895
	VISIT DATE: 07/14/2023

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Care & Supervision/Administration: Adequate staff are present for the supervision of residents during the visit. LPA also reviewed the staff scheduled 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.

Record Review and Resident/Staff Files: LPA reviewed two (2) staff files and training. All staff updated training along with CPR/First Aid Certification. LPA observed Staff # 1 (S1) did not have criminal record clearance and was working at this facility for approximately one month. A civil penalty will be issued. Three (3) resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All resident medication was locked in a closet near the kitchen. LPA reviewed medications for (3) residents and found all medication listed on MARS and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA interviewed Licensee regarding fire and earthquake drill and he stated the facility holds monthly staff training for fire and earthquake drills which met the department requirements. LPA advised to have written documentation available at the facility of the fire and earthquake drills. Technical Assistance will be issued. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items.

An exit interview was conducted where a copy of this report, LIC809D, Civil Penalty, and appeal rights was provided to Licensee, Matthew Siegel.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/14/2023 01:40 PM - It Cannot Be Edited

Created By: Sara Martinez On 07/14/2023 at 01:06 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: 07/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in having staff # 1 (S1) working at the facility without a criminal record clearance from the DOJ for approximately a month which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/15/2023
	Plan of Correction
1 2 3 4	During the visit Licensee immediately removed S1 from the facility. S1 will be able to work again at the facility once criminal record clearance can be confirmed. Licensee will further conduct in-service training on the title 22 reguations regarding Criminal Record Clearance and provide proof of such by POC.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Sara Martinez

LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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