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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425566
Report Date: 06/27/2024
Date Signed: 06/27/2024 12:13:52 PM

Document Has Been Signed on 06/27/2024 12:13 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:HOVLEY CARE LLCFACILITY NUMBER:
336425566
ADMINISTRATOR/
DIRECTOR:
SVETLANA CALAMAROFACILITY TYPE:
740
ADDRESS:40827 HOVLEY COURTTELEPHONE:
(760) 568-4100
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY: 6CENSUS: 3DATE:
06/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Alicia Sical-Castenada - CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with caregiver Alicia Sical-Castenada, who was informed of the purpose of the visit. At the time of the visit there was one (1) staff and three (3) resident present. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Facility pool had a locked gate. Detergents, cleaning solutions, and sharp and dangerous objects were observed to be locked and inaccessible. The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Records review revealed Licensee has not paid their annual fee since 2021. A deficiency cited under Title 22 Regulation 87156(a) will be issued. LPA reviewed two (2) staff files and training. Records review of Staff One (S1) and Staff Two (S2) did not have updated CPR/First Aid training in their file. Last documented training completed for CPR/First Aid for S1 and S2 was in 2019. A deficiency cited under Healthy and Safety Code 1569.618(c)(3) will be issued. All staff have the required personnel records on file and criminal record clearance. Two (2) resident files were reviewed and possessed all required paperwork which included Admissions Agreement and Physician's Report. Resident medication was centrally stored and locked in a cabinet located in the kitchen. Facility had a centrally stored medication list dated 03/14/2024 for Resident One (R1) that had inconsistencies with the medication available at the facility A deficiency cited under Title 22 Regulation 87465(a)(6) will be issued. LPA reviewed the facility's emergency and disaster plan. All facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. Fire extinguishers were fully charged and inspected. Facility did not have written documentation of quarterly disaster drills being conducted in the year of 2024. A deficiency cited under Healthy and Safety Code 1569.695(c) will be issued.



An exit interview was conducted where a copy of this report, LIC 809-D, LIC 811, and appeal rights was provided to caregiver Sical-Castenada.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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 4
Document Has Been Signed on 06/27/2024 12:13 PM - It Cannot Be Edited


Created By: Sara Martinez On 06/27/2024 at 11:19 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: HOVLEY CARE LLC

FACILITY NUMBER: 336425566

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in two (2) out of two (2) staff who do not have documentation of the training available for review during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Licensee will ensure staff have conducted the training listed above and send proof of completion for Staff One (S1) and Staff Two (S2) by the agreed plan of correction date 07/12/2024
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above for Resident One (R1) who did not have a updated record of the centrally stored medication list, the most recent list is dated 03/14/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Licensee will ensure the facility maintains an updated centrally stored medication list for R1 and other residents in care. Licensee will send proof of a updated centrally stored medication list for R1 by the agreed plan of correction date 07/12/2024.
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:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/27/2024 12:13 PM - It Cannot Be Edited


Created By: Sara Martinez On 06/27/2024 at 11:19 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: HOVLEY CARE LLC

FACILITY NUMBER: 336425566

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in conducting a quarterly disaster drills with staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Licensee will read the regulation cited and conduct a type of disaster drill with staff from the AM shift and PM shift. Licensee will submit proof of training and the materials covered during the training to LPA by the agreed plan of correction date 07/12/2024.
Type B
Section Cited
CCR
87156(a)
(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.

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 in paying their annual licensing fee since the year 2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Licensee will ensure fees are paid and will submit proof of payment to LPA by the agreed plan of correction date 07/12/2024.
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:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4