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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881119
Report Date: 04/17/2024
Date Signed: 04/17/2024 12:14:36 PM

Document Has Been Signed on 04/17/2024 12:14 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:VICTORIA FALLS HOME CAREFACILITY NUMBER:
331881119
ADMINISTRATOR/
DIRECTOR:		CLARK, ZINICAFACILITY TYPE:
740
ADDRESS:78554 PLEASANT DRIVETELEPHONE:
(760) 464-0236
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY: 6CENSUS: 3DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Zinica Clark - Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator/Licensee Zinica Clark and informed her of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include soap and paper towels at hand washing stations, and hand washing guides posted above sinks.

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 118 degrees. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. Knives and other sharp objects are kept in the locked garage. LPA Colvin observed Comet and Windex cleaners under the kitchen sink. The facility has residents with Dementia, and therefore these items pose a risk to the residents since they were accessible. Deficiency cited.

Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 non-ambulatory residents. Facility has a hospice waiver for 6 residents.

Planned Activities: LPA Colvin confirmed with interviews of staff and residents that the facility provides activities for residents to engage in and are tailored to their interests.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: VICTORIA FALLS HOME CARE
FACILITY NUMBER: 331881119
VISIT DATE: 04/17/2024
NARRATIVE
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Incidental Medical Services: LPA Colvin observed that resident medication is locked in a closet and inaccessible to residents. LPA Colvin observed that the facility has a Medication Administration Log (MAR) for each resident, but they are not tracking the doses of medication administered. The facility is not required to use a MAR log, but LPA Colvin is issuing a Technical Advisory Note to suggest that the facility either fully use the log, or to not use it at all. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions.

Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that the facility has an Administrator with a current Administrator Certificate. LPA Colvin reviewed staff records and confirmed current CPR/First Aid Certification as well as training relevant to the facility and residents' needs. LPA Colvin observed that one staff member (S1) has expired CPR/First Aid Certification. Deficiency cited.

Resident Records: LPA Colvin reviewed the files for all 3 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin observed that R1's file does not contain a completed Needs and Services Plan. Deficiency cited.

Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file and the facility staff are conducting drills quarterly.



An exit interview was conducted with Administrator/Licensee Zinica Clark and a copy of this report, LIC809Ds, LIC9102 TV, LIC9098 Proof of Corrections, and appeal rights were provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/17/2024 12:14 PM - It Cannot Be Edited


Created By: Crystal Colvin On 04/17/2024 at 11:42 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: VICTORIA FALLS HOME CARE
FACILITY NUMBER: 331881119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two chemicals (Comet and Windex) which poses an immediate health and safety risk to persons in care. LPA Colvin observed Comet and Windex in an unlocked cabinet under the kitchen sink
POC Due Date: 04/18/2024
Plan of Correction
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Licensee agrees to move chemicals to a secured location and have a meeting with staff regarding ensuring all chemicals are kept locked and secured. Licensee may self-certify to LPA Colvin once complete.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tricia Danielson
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/17/2024 12:14 PM - It Cannot Be Edited


Created By: Crystal Colvin On 04/17/2024 at 12:04 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: VICTORIA FALLS HOME CARE
FACILITY NUMBER: 331881119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements – General: (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement was not met as eviddnced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 staff member (S1), which poses/posed a potential health and safety risk to persons in care. LPA Colvin observed that S1 has expired CPR/First Aid certification (expired 3/1/24).

POC Due Date: 05/01/2024
Plan of Correction
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Licensee agrees to have S1 obtain a renewal of CPR/First Aid Certification and to provide LPA Colvin a copy by the Plan of Correction date of 5/1/24

Type B
Section Cited
CCR
87560(a)
Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in1 of 3 residents, which poses a potential health or personal rights risk to persons in care. LPA Colvin observed that there was no completed Needs and Services Plan in R1's file.
POC Due Date: 05/01/2024
Plan of Correction
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Licensee agrees to complete a Needs & Services Plan for R1 and review it with R1 and their representative. Licensee to provide a copy of the Plan to LPA Colvin by Plan of Correction date of 5/1/24.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
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