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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208789
Report Date: 10/24/2022
Date Signed: 10/24/2022 05:31:36 PM


Document Has Been Signed on 10/24/2022 05:31 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 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: 6DATE:
10/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:LIza ArateaTIME COMPLETED:
05:53 PM
NARRATIVE
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On 10/24/2022, Licensing Program Analysts (LPAs) M. Medina and L.Salazar conducted a Case Management visit observed during Annual Required Infection Control inspection.

During the course of Inspection is was observed that 5 of 6 residents had full bed rails and not receiving hospice services. R5 has a prohibited condition being treated by Home Health.

Deficiencies cited on the attached 809-D.

Based on today's visit, a deficiency is being cited, per California Code of Regulations, Title 22, Division 6, Chapter on the attached 809D. A Civil Penalty is being assessed in the amount of $500.

Exit interview conducted. Appeal rights provided. A copy of this report was provided for facility records.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
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 2


Document Has Been Signed on 10/24/2022 05:31 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: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2022
Section Cited

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5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.(A) Bed rails that extend the entire length of the bed are prohibited except for
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residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
**This was not met as evidenced by 5 of 6 residents have full bed rails and not on hospice
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POC due date

**Immediate Civil Penalty Assessed
Type A
10/25/2022
Section Cited

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Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care
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facility for the elderly. (1)Stage 3 and 4 pressure injuries.

**This was not met as evidenced by R5 has a Stage 3 pressure injury being treated by Home Health.
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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) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2