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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412698
Report Date: 04/23/2021
Date Signed: 04/23/2021 01:52:01 PM

Document Has Been Signed on 04/23/2021 01:52 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AFFINITY SENIOR LIVING 2FACILITY NUMBER:
336412698
ADMINISTRATOR:ANALISA CAYABYABFACILITY TYPE:
740
ADDRESS:28200 HORIZON ROADTELEPHONE:
(760) 864-3259
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 9CENSUS: 9DATE:
04/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Analisa Cayabyab, AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate an investigation into complaint #18-AS-20210422092430. Upon the visit, a violation of fire clearance was observed.

The LPA observed a lock on the front gate obstructing the entrance to the facility. This posed an immediate threat to the residents in care. Therefore, a citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

This report was reviewed with Cayabyab and a copy provided via email.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2021
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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Document Has Been Signed on 04/23/2021 01:52 PM - It Cannot Be Edited


Created By: Stephanie Torres On 04/23/2021 at 10:41 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: AFFINITY SENIOR LIVING 2
FACILITY NUMBER: 336412698

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2021
Section Cited
CCR
87202(a)

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FIRE CLEARANCE: All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...This requirement was not met as evidenced by: Based on observation the Licensee did not ensure approval was received
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Facility staff removed the lock. POC cleared.
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by the State Fire Marshall to lock an exterior gate. The LPA observed a lock on the front gate obstructing the front entrance to the facility. This posed an immediate threat to the residents in care.
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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:Reyna Lacey
LICENSING EVALUATOR NAME:Stephanie Torres
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2021


LIC809 (FAS) - (06/04)
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