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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880999
Report Date: 10/21/2024
Date Signed: 10/21/2024 11:46:11 AM

Document Has Been Signed on 10/21/2024 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:MD PREMIER CARE HOMEFACILITY NUMBER:
331880999
ADMINISTRATOR/
DIRECTOR:		DOLHA, MIRCEAFACILITY TYPE:
740
ADDRESS:45911 PASEO CORONADOTELEPHONE:
(949) 335-2364
CITY:INDIAN WELLSSTATE: CAZIP CODE:
92210
CAPACITY: 6CENSUS: 3DATE:
10/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Mircea DolhaTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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Licensing Program Analysts (LPAs) Abdoulaye Zerbo, Debbie Palacio and LPM Tricia Danielson conducted an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPAs were greeted by Mircea Dolha, 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 6 residents bedrooms, 1 staff bedroom and 6 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. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in kitchen cabinet next to the fridge 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 09/20/2025. LPAs observed the hot water temperature to meet requirements at 106.2°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.


Continued on LIC809-C.....
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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: MD PREMIER CARE HOME
FACILITY NUMBER: 331880999
VISIT DATE: 10/21/2024
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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 June 22th, 2026 and a CPR certification with the expiration date of 10-25-25

Record Review and Resident/Staff Files: LPAs reviewed files for two(2) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Three residents' files were reviewed and contained all required documentation. LPA's observed Staff, resident files, were stored in a cabinet next to the kitchen and emergency food was stored in the laundry room. The first aid kit was stored in the kitchen area


Health-Related Services/Incidental Medical Services: All residents' medications were securely locked and located in the kitchen area. LPAs reviewed medications for three residents, confirming that all medications were listed and accounted for.

Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 10-01-2024, 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 Mircea Dolha
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC809 (FAS) - (06/04)
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