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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881535
Report Date: 04/02/2024
Date Signed: 04/02/2024 02:57:24 PM

Document Has Been Signed on 04/02/2024 02:57 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:A ROMERO'S RETREATFACILITY NUMBER:
331881535
ADMINISTRATOR:ROMERO, DEBORAH DAWNFACILITY TYPE:
740
ADDRESS:31758 WHISPERING PALMS TRAILTELEPHONE:
(760) 578-5854
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 4CENSUS: 0DATE:
04/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Licensee, Deborah RomeroTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At 1:00 PM, LPA met with Licensee, Deborah Romero. An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 11/25/2023 for a total capacity of four (4) residents. Fire clearance was granted on 12/18/2023 by the Cathedral City Fire Department. LPA Kathleen Banrasavong observed the following:
Structure:
Facility is a one-story house with four (4) bedrooms, four (4) bathrooms, living room, dining area and kitchen. There was an attached two car garage. There is not a pool.
Heating/Cooling System:
Central heating and air conditioning system are installed and operable. Temperature was set at 75 degrees.
Bedrooms:
Each resident bedroom #1, #2, #3, #4 were in good repair. Three (3) out of the four (4) bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm and carbon monoxide alarms. Bedroom #2 did not have a bed or a nightstand.
Bathrooms:
Four (4) bathrooms have a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and hand soap dispensers. LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 106 degrees Fahrenheit.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
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: A ROMERO'S RETREAT
FACILITY NUMBER: 331881535
VISIT DATE: 04/02/2024
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Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. There was not a location for knives/sharps. There was adequate room for food storage. LPA observed the stove and microwave to be operational. Refrigerator/freezer were in working condition.
Pantry had sufficient storage for non-perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in hallway to the garage. Laundry detergents and cleaning supplies were observed in the hallway in the laundry area.
Living/Family room:
There was a living room with furniture for all clients.
Linens and Hygiene Supplies:
An adequate supply of linens and hygiene supplies was stored in a cabinet in the hallway of the residence.
Yards/Outside:
Patio table and chairs were observed in the backyard. There was a gate on the northwest and northeast with a self-latching closure. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted at the exits in the house. Ombudsman poster, Let-Us-No poster, Rights of Resident Council, Theft & Loss, Personal rights, Non-discrimination observed.
General items:
Two (2) fire extinguishers was charged and located in the closet with signage; fire extinguisher was bought 11/30/2023. Six (6) dual smoke alarms and carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked closet. Three (3) First Aid kits with required components were observed. There was a locked area for medication storage. Emergency food and water supply was observed. Pre-Licensing is complete, and this facility has five (5) deficiencies that need to be corrected and sent to the LPA by April 16th, 2024.
An exit interview was conducted, the LIC 9102s and a copy of this report was given Licensee, Deborah Dawn Romero.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC809 (FAS) - (06/04)
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