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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208789
Report Date: 06/02/2021
Date Signed: 08/24/2021 02:35:45 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/25/2021 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20210525160626
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
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Licensee Ana Liza ArateaTIME COMPLETED:
08:00 PM
ALLEGATION(S):
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Facility accepted a resident without an admission agreement
INVESTIGATION FINDINGS:
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On 06/02/2021, Licensing Program Analysts (LPA) L. Salazar and S. Doucette arrived to the facility unannounced to conduct the required 10 day inspection. LPAs conducted interviews with the reporting party and licensee. LPA requested to see the following documentation:

1.) Admission Agreement for Residents in care
2.) Pre-Admission Appraisal for residents in care

During the course of the investigation, LPAs toured the facility, conducted interviews and reviewed resident files for records maintained at the facility.

Based on interviews and observation of record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6, see LIC 9099D. Exit interview conducted and appeal rights given.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20210525160626
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 B
06/04/2021
Section Cited
CCR
87506(b)(17)(A)
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Admission Agreement
(b) Each resident’s record shall contain at least the following information:(17) Documents and information required by the following:(A) Section 87457, Pre-Admission Appraisal; This requirement was not met as evidenced by LPA's review of all residents records. No pre-appraisal has been completed or maintained in the resident files.
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Licensee will review, sign and date and the Title 22 regulation being cited. Licensee will ensure all admission agreements are prepared and filled out in their entirety before accepting a new resident.
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Type B
CCR
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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: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/25/2021 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20210525160626

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
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Licensee Ana Liza ArateaTIME COMPLETED:
08:00 PM
ALLEGATION(S):
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Facility is unclean
Staff failed to meet residents' needs
INVESTIGATION FINDINGS:
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On 06/02/2021, Licensing Program Analysts (LPA) L. Salazar and S. Doucette arrived to the facility unannounced to conduct the required 10 day inspection. LPAs toured the facility and observed bedrooms, bathrooms, living areas and kitchen clean and free from odor. LPAs observed 5 residents in the facility. LPA's reviewed residents' files and facility records.

This agency has investigated the above allegation. Based on LPAs observations, this allegation is UNFOUNDED. No Deficiency cited.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 3