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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208789
Report Date: 08/11/2021
Date Signed: 08/15/2021 03:39:54 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:
08/11/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 AM
MET WITH:Ana Liza Aratea, Licensee TIME COMPLETED:
10:45 AM
NARRATIVE
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On 08/11/21, Licensing Program Analysts (LPAs) L.Salazar and S. Doucette arrived at the facility unannounced to conduct a Health & Safety inspection to verify care and supervision. LPAs obtained information there was no staff in the facility at night. LPAs rang the doorbell, no one answered. LPAs called the facility phone which went straight to a fax machine. Licensee arrived at the facility shortly after.

LPAs toured the facility and checked on residents in care. LPA Salazar requested to see staff files and resident files. LPAs observed Resident R1, who is bedridden and not receiving Hospice or Home Health care. R1 is in need of 24 hour nursing care.

LPAs attempted to interview staff on site and were unsuccessful due to licensees interference and refusal to allow LPAs to interview staff.

LPA Salazar reviewed facility Hospice Initiation requests for Residents R5, R6, and R7. Residents passed away in 2020 and 2021. No Death Reports were submitted. Based on number of deficiencies, reduction of Hospice Waiver is under review. Informal Meeting with licensee has been scheduled for 08/26/21.

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

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
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
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: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2021
Section Cited

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(c) No resident shall be accepted or retained if any of the following apply:(2) The resident requires 24-hour, skilled nursing or intermediate care as specified in Health and Safety Code Sections 1569.72(a) and (a)(1).
This requirement was not met as evidenced by LPAs observation of Resident R1. R1 requires 24 hour skilled nursing care. Hospice care was terminated as of 06/24/21. No evidence of any other services being provided.
Type A
08/11/2021
Section Cited

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87207 False Claims
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by licensee giving a false name and employee file of an employee who was not fingerprint cleared or listed on the facility roster.
Type A
08/11/2021
Section Cited

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The licensee shall ensure that provisions are made for private interviews with any resident or any staff member; and for the examination of all records relating to the operation of the facility. This requirement was not met as evidenced by LPA Doucette's observation of LPA Salazar's efforts to speak to Staff S1 and Staff S2 privately. Licensee would not leave the area and was responding to LPA's questions to S1 & S2.
Type B
08/13/2021
Section Cited

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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 Resident R5's Death Report LIC624a being received 11days after the death. No Death Report was received for Resident R6,R7, R5.
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: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021
LIC809 (FAS) - (06/04)
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