Facility Evaluation Report

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of investigating a complaint (#18-AS-20210824111213). During LPA Colvin's inspection, LPA Colvin observed additional items that needed to be addressed with the Administrator. Below is a summary of what was observed:

Unassoicated Staff - LPA Colvin observed that two staff members (S1 & S2) are working at the facility but are not associated. LPA Colvin was able to confirm background clearance for both staff, but in review of their files at the facility LPA Colvin did not locate a clearance transfer request to the facility, which is required for the staff to be associated. A facility must have submitted a transfer request for staff with background clearance prior to them working in the facility. Deficiency cited . This deficiency comes with a civil penalty in the amount of $100 per day, per staff, for a maximum of 5 days. Since both staff have worked at the facility for longer than 5 days, the maximum penalty of $500 per staff ($1,000 total) will be assessed.

Locked Perimeter - LPA Colvin observed that the facility's front and side gate both have an electronic lock which requires a security code to unlock. LPA Colvin reviewed the facility's application and fire clearance and observed that the facility has not been approved for a locked perimeter. LPA Colvin additionally contacted the Cathedral City Fire Department and confirmed that the Fire Marshall did not approve the locked perimeter. Deficiency cited. A violation of a facility's fire clearance comes with an immediate civil penalty in the amount of $500, which will be assessed today. Licensee requested LPA Colvin to submit request to Fire Department for inspection for approval for delayed egress .

Resident Funds - LPA Colvin observed that the facility is holding on to resident funds (average of $200 for each resident). LPA Colvin reviewed the facility's application for license and confirmed that it was stated to Licensing that they would not handle resident funds. Deficiency cited.