157208789-10-24-2023-24-AS-SDOE-CWX5U3-20231024201516

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157208789
Report Date: 10/24/2023
Date Signed: 10/24/2023 08:18:18 PM

Document Has Been Signed on 10/24/2023 08:18 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, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	SIMPLY CARING ANGELS LLC		FACILITY NUMBER:	157208789
ADMINISTRATOR:	ANA LIZA P ARATEA		FACILITY TYPE:	740
ADDRESS:	608 WEST WASP AVENUE		TELEPHONE:	(760) 793-2307
CITY:	RIDGECREST	STATE: CA	ZIP CODE:	93555
CAPACITY:	6	CENSUS: 3	DATE:	10/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Ana Liza Aratea		TIME COMPLETED:	04:30 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst's (LPA)'s LPA Shawna Doucette and LPA Miriam Flores arrived at the facility unannounced to conduct an annual inspection. LPA's was granted entry by Staff, Cipriana Dela Cruz. LPA explained the purpose of the visit and Administrator Ana Liza Aratea responded to the facility to meet LPA's to conduct the visit.

A tour of the facility was conducted with the Administrator. The residence was set at 78 F temperature and free of passageway obstructions inside and outside.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked Medication cabinet in the kitchen. Cleaning supplies were unlocked in a cabinet above the washing machine. Smoke detectors and carbon monoxide detectors were checked and properly working. Fire extinguishers were charged and had service dates of 05/22/23. LPA checked water temperature which measured at 110.6 F.

There was outdoor seating for the residents.

Resident, medication and staff records were reviewed. LPA observed a medication error for R1. R1 medication count did not match start date on centrally stored log. Facility staff did not have hospice or home health training. Facility did not have home health care plans or hospice care plans for all residents. Current first aid and CPR were reviewed.

LPA took photos of medications and unlocked cleaning supply cabinet.

Refer to 809d for deficiencies

A copy of this report with plan of correction and appeal rights were provided to the Administrator.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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 5

Document Has Been Signed on 10/24/2023 08:18 PM - It Cannot Be Edited

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: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having the cleaning supplies cabinet unlocked and accessible to residents with dementia, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2023
	Plan of Correction
1 2 3 4	Licensee agrees to lock cleaning supplies and keep them inaccessible to residents in care. Cabinet was locked during visit.

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by Licensee did not administer R1's medications correctly after conducting a pill count and comparing to centrally stored log R1s medication should have started on 10/17/23 not 10/20/23, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2023
	Plan of Correction
1 2 3 4	Licensee agrees to conduct staff training on medications and agrees to submit training agenda, who provided the training and staff that was trained by POC due date 11/20/23

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 Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 10/24/2023 08:18 PM - It Cannot Be Edited

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: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(e)

Incidental Medical and Dental Care Services

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in Licensee did not have a written order for R2's medication which Licensee stated is a PRN however it states to be administered daily, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2023
	Plan of Correction
1 2 3 4	Licensee was able to provide physician order stating R2's medication was a PRN and not a medication to be administered daily. Corrected during visit.

Type B

Section Cited

HSC

1569.39(b)

Regulations

(b) A residential care facility for the elderly that accepts or retains residents with restricted health conditions, as defined by the department, shall ensure that residents receive medical care as prescribed by the resident’s physician and contained in the resident’s service plan by appropriately skilled professionals acting within their scope of practice. An appropriately skilled professional may not be required when the resident is providing self-care, as defined by the department, and there is documentation in the resident’s service plan that the resident is capable of providing self-care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in Licensee did not have a plan of care or physician care documentation for R1, R2, or R3 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a written understanding of this regulation and how it will be met in the future by POC due date 11/20/23.

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 Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 10/24/2023 08:18 PM - It Cannot Be Edited

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: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87616(b)(1)

Exceptions for Health Conditions

(b) Written requests shall include, but are not limited to, the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in Licensee did not have any documentation from the physician or from home health regarding the stage of R1's wounds, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/27/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a written understanding of this regulation and an exception if the wound is over a stage 2 by POC due date 10/27/23.

Type B

Section Cited

CCR

87463(a)(3)

Exceptions for Health Conditions

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having R1's reappraisal complete with change in condition which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/27/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a reappraisal of R1 by POC due date 11/20/23.

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 Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 10/24/2023 08:18 PM - It Cannot Be Edited

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: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87633(b)

Hospice Care for Terminally Ill Residents

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in Licensee does not have a hospice care plan for R2 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/27/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a hosipice care plan for R1 that meets this regulation by POC due date of 10/27/23

Type B

Section Cited

CCR

87633(b)(6)

Hospice Care for Terminally Ill Residents

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in Licensee did not have any documentation of staff training from hospice for R2, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/27/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit staff training which shows hospice trained facility staff on how to care for R2 by POC due date 10/27/23

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 Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5