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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208789
Report Date: 08/05/2021
Date Signed: 08/08/2021 08:11:00 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:
08/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ana Liza Aratea, LicenseeTIME COMPLETED:
07:30 PM
NARRATIVE
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On 08/05/2021, at 12:30pm, Licensing Program Analysts (LPAs) L. Salazar and LPA S. Doucette conducted an unannounced Annual Required Inspection and met with Licensee, Ana Liza Aratea. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee. 5 residents and 2 staff were present in the facility during the inspection. The facility is a 6 bedroom, 3 1/2 bathroom house. Licensee accompanied LPA inside and out of the facility during this inspection.

LPA inspected the kitchen area and observed a two-day supply of perishable and a seven day supply of non-perishable food. Knives and toxics were kept in an unlocked kitchen cabinet under the sink.

At 12:30pm, LPA tested one carbon monoxide detector and one smoke detector located in the hallway area. Both devices were functional.

Deficiencies are being cited based on LPAs observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see 809 D.

An exit interview was conducted and Plans of correction were reviewed and developed with the licensee. A copy of this report and appeal rights were discussed and left with licensee.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
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 3
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: 08/05/2021

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
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Based on observation, the licensee did not comply with the section cited above by having a unlocked kitchen cabinet containing knives and cleaning supplies for 5 out of 5 dementia residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2021
Plan of Correction
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Licensee locked kitchen cabinet containing chemicals and knives. Licensee will ensure staff will keep cabinet locked at all times. ** POC cleared at the time of visit**
Type A
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 record review, the licensee did not comply with the section cited above. Licensee was unable to provide documentation of quarterly fire drills which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2021
Plan of Correction
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Licensee will provide proof of documented emergency fire drill training with all staff.
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: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 08/05/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(E)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information requried by the following: (E) Section 87463, Reappraisals; and

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 5 out of 5 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2021
Plan of Correction
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Licensee will provide copies of reappraisals for all residents in care.
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

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 5 out of 5 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2021
Plan of Correction
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Licensee has added the pre appraisal to the admission agreement packet and understands that all pre-appraisals must be done prior to admission. ** POC Cleared at visit**
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: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021
LIC809 (FAS) - (06/04)
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