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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208789
Report Date: 06/02/2021
Date Signed: 06/02/2021 07:43:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SIMPLY CARING ANGELS LLCFACILITY NUMBER:
157208789
ADMINISTRATOR:ANA LIZA P ARATEAFACILITY TYPE:
740
ADDRESS:608 WEST WASP AVENUETELEPHONE:
(760) 793-2307
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY:6CENSUS: 5DATE:
06/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Licensee Ana Liza P ArateaTIME COMPLETED:
08:00 PM
NARRATIVE
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On 6/2/2021, Licensing Program Analyst (LPA)s Shawna Doucette and LIsa Salazar contacted Licensee Ana Liza P Aratea to conduct a Case Management visit. LPAs introduced themselves and discussed the purpose of the visit with Licensee.

The purpose of today's visit was to open complaint number 24-AS-20210525160626. During the visit, LPA's found additional deficiencies.


Based on interviews conducted, tour of facility and records review, deficiencies and Civil Penalty are being issued in the areas evaluated and listed on the 809-D according to California Code of Regulations Title 22, Division 6 and Health and Safety Code.

An exit interview was conducted and Plan of Correction was reviewed and developed with the Licensee. Licensee was provided with a copy of this report and Appeal Rights.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SIMPLY CARING ANGELS LLC
FACILITY NUMBER: 157208789
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2021
Section Cited

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87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment. This requirement was not met evidenced by


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Licensee not having trained staff to operate all oxygen equiptment for residents in care. Based on review of records and interview with Licensee, Licensee did not not have training for staff to operate oxygen equiptment, which poses an immediate health and safety risk to residents in care.
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Type A
06/24/2021
Section Cited

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87613 General Requirements for Restricted Health Conditions
(a) Prior to admission of a resident with a restricted health condition, the licensee shall:(2) Ensure that facility staff who will participate in meeting the resident’s specialized care needs complete training provided by a licensed professional sufficient to meet those needs.(B) Training shall be completed prior to the staff providing services to the resident.
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This requirement was not met as evidenced by interviews with licensee and the lack of documentation( no care plans) received from the licensee. Based on review of records, Licensee did not have training for staff to care for hospice residents, which poses an immediate health and safety risk for 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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SIMPLY CARING ANGELS LLC
FACILITY NUMBER: 157208789
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2021
Section Cited

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87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.
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This requirement was not met as evidenced by Licensee not notifying the local fire department of oxygen dependent residents. Based on review of records and interview with Licensee, Licensee did not notify the local fire department of oxygen dependent residents, which poses an immediate health and safety risk for residents in care.
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Type A
06/24/2021
Section Cited

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.


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This requirement was not met as evidenced by Licensee not having a current medical assessment for R1. Based on review of records and interview with Licensee, Licensee did not have a current assessment for R1 since 2017, which poses an immediate health and safety risk for 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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SIMPLY CARING ANGELS LLC
FACILITY NUMBER: 157208789
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2021
Section Cited

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1569.73 Terminally ill residents; or terminally ill persons to be accepted as a resident; transferring hospice care and waivers; resident care and supervision (h) Nothing in this section shall be construed to relieve a licensed residential care facility for the elderly of its responsibility to notify the appropriate fire authority of the presence of a bedridden resident in the facility as required under subdivision (f) of Section 1569.72, and to obtain and maintain a fire clearance as required under Section 1569.149.


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This requirement was not met as evidenced by Licensee not notifying the local fire department of admitting 5 bedridden residents. Based on review of records and interview with Licensee, Licensee did not notify the local fire departmet of admitting 5 bedridden residents and obtaining the proper fire clearance.
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Type B
06/17/2021
Section Cited

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Reporting Requirements Reporting Requirments: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence.other death reports were not submitted.This requirement was not met as evidenced by late reporting
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date stamped from CCL on 3/19/21 for a death that occured on 3/1/21 and while reviewing records it was found other death reports were not submitted. Based on interview and review of records Licensee did not have death reports for residents that were 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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4