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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881351
Report Date: 02/29/2024
Date Signed: 02/29/2024 10:51:06 AM

Document Has Been Signed on 02/29/2024 10:51 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:ASHER'S RESIDENTIAL CARE FACILITYFACILITY NUMBER:
331881351
ADMINISTRATOR:MALIGAYA, MARK ANTHONYFACILITY TYPE:
740
ADDRESS:1666 SAGEBRUSH ROADTELEPHONE:
(760) 844-0754
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92264
CAPACITY: 6CENSUS: 6DATE:
02/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Mark Maligaya - AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
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During Licensing Program Analyst (LPA) Crystal Colvin's inspection at the facility to conduct an inspection. During the inspection, LPA Colvin confirmed that Resident One (R1) was taken to the hospital via 911 on 2/21/24, but the facility did not submit an Unusual Incident Report to Licensing. Deficiency cited. LPA Colvin counseled Administrator Mark Maligaya and informed him of the circumstances in which Licensing should be notified of an event occurring with a resident. LPA Colvin additionally advised the Administrator of proper procedure for submitting reports, as LPA Colvin observed that no Incident Reports or Death Reports have been submitted to Licensing since the issuing of this license.

Based on LPA Colvin's observations, the facility was cited and deficiency issued. LPA Colvin conducted an exit interview with Administrator Mark Maligaya and a copy of this report, LIC809D, LIC9098 Proof of Correction Form, and appeal rights were provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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 2
Document Has Been Signed on 02/29/2024 10:51 AM - It Cannot Be Edited


Created By: Crystal Colvin On 02/29/2024 at 10:34 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: ASHER'S RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 331881351

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
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...within seven days of...(D) Any incident which threatens the welfare, safety or health of any resident... This was not met by:
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Administrator states that he will retake training on Reporting Requirements and submit an Incident Report for the event from 2/21/24. Administrator to provide report and proof of training by Plan of Correction date of 3/15/24.
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Based on interview and record review, the Licensee did not comply with the above regulation with at least one incident. R1 was taken to the hospital via 911 on 2/21/24 and no report was submitted to Licensing. This is a potential personal rights risk to 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:Rikesha Stamps
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2