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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881681
Report Date: 04/21/2025
Date Signed: 04/21/2025 11:25:09 AM

Document Has Been Signed on 04/21/2025 11:25 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:GOOD NESTS, THEFACILITY NUMBER:
331881681
ADMINISTRATOR/
DIRECTOR:		MONTOYA, TIFFANYFACILITY TYPE:
740
ADDRESS:891 S AVENIDA EVELITATELEPHONE:
(949) 791-7665
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92264
CAPACITY: 6CENSUS: 0DATE:
04/21/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Tiffany MontoyaTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an announced pre-licensing inspection at the facility and met with Administrator Tiffany Montoya

Application: The inspection is an initial application for a Residential Care Facility for Elderly (RCFE). The Palm Springs Fire Department approved a fire clearance on 03-20-2025 for five (5) non-ambulatory clients and one(1) bedridden in bedroom one

Buildings and Grounds: The facility is composed of three (3) residents' bedrooms, one(1) staff bedroom, two (2) bathrooms, a living room a kitchen area, and a garage. Water temperature was measured at 76.5 F. The licensee stated they had hot water few days ago. They stated they will have maintenance fix it and provide proof of correction. The interior and exterior walkways of the facility were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were in working order. There is a no pool and there are no weapons stored in the facility. Residents' bedrooms are fully furnished, and privacy is available. Outdoor areas have sufficient room for activities and leisure. A washing machine and dryer were available and in working order. The facility has a working phone witnessed by calling the phone number.

Storage and Supplies: Medications, residents and staff files will be stored in a locked cabinet in the kitchen area, inaccessible to any unauthorized individuals. A complete first aid kit was observed to be available. Cleaning supplies will be stored under the kitchen sink. Linens, and equipment appeared to be in good repair and sufficient for the approved census. Fire extinguishers were available and fully charged with an expiration date of February 26th, 2026.
NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Abdoulaye Zerbo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: GOOD NESTS, THE
FACILITY NUMBER: 331881681
VISIT DATE: 04/21/2025
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Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and freezer are in working order. Sharps knives will be stored in a locked cabinets in the kitchen area, available only to authorized individuals.

Forms: The following signs were observed to be posted at the facility: Personal Rights, Complaint information, Emergency disaster plan, the facility sketch. LPA verified the Administrator's Certification, with an expiration date of April 16, 2026 and CPR certification with the expiration date of October-30-26.

The applicant will be contacted by the regional office to schedule the Comp III. LPA determined the facility does not meets the operational requirements for licensure. The Pre-Licensing is incomplete with deficiencies to be resolved by May 5th 2025 . A follow up Pre-licensure visit will be conducted upon resolution of deficiencies. An exit interview was conducted, and this report was discussed and a copy was provided to Administrator Tiffany Montoya.

NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Abdoulaye Zerbo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC809 (FAS) - (06/04)
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