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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424971
Report Date: 11/08/2023
Date Signed: 11/08/2023 02:33:50 PM

Document Has Been Signed on 11/08/2023 02:33 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HIGH DESERT RESIDENTIAL CARE, LLCFACILITY NUMBER:
366424971
ADMINISTRATOR:YIP, TERESAFACILITY TYPE:
740
ADDRESS:8980 JOSHUA LANETELEPHONE:
(760) 853-0464
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY: 12CENSUS: 8DATE:
11/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Caitlin BelisleTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Caitlin Belisle, Direct Support Provider and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (12) with a current census of (8). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: Indoor and outdoor passageways are free of obstruction. Facility pool is fenced and observed locked, inaccessible to residents in care. Facility has sufficient indoor and outdoor shaded space for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s bathrooms were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured between 107 to 118 degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. Facility a fully charged fire extinguisher and several carbon monoxide alarms. Fireplace is adequately screened. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, disaster evacuation plan and emergency telephone numbers.
Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Soaps and other cleaning solutions were stored away from food areas.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HIGH DESERT RESIDENTIAL CARE, LLC
FACILITY NUMBER: 366424971
VISIT DATE: 11/08/2023
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Care & Supervision: Facility has 24-hour care staff. Staff working have criminal record clearances or exemptions through the Department.
Record Review: (3) staff files reviewed were observed to be complete. (3) resident files reviewed were observed to be complete. Administrator’s certification expires on 8/8/2024. Facility had no documentation of last emergency drill conducted on file. Deficiency cited.
Medical Related Services: All medication is centrally stored and locked in a cabinet located in the dining area.

A deficiency is being cited during today's visit. An exit interview was conducted where reports LIC809 & LIC809D were discussed. Copies with appeal rights were provided to the Direct Support Provider.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2023 02:33 PM - It Cannot Be Edited


Created By: Magda Malcore On 11/08/2023 at 02:18 PM
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: HIGH DESERT RESIDENTIAL CARE, LLC
FACILITY NUMBER: 366424971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2023

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 LPA file review, the licensee did not comply with the section cited above by facility had no documentation of last emergency drill conducted on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Licensee/Administrator shall submit to the licensing agency proof of emergency drill conducted by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023


LIC809 (FAS) - (06/04)
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