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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005870
Report Date: 01/24/2025
Date Signed: 01/24/2025 04:11:08 PM

Document Has Been Signed on 01/24/2025 04:11 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ANGELIC DWELLING CARE HOMEFACILITY NUMBER:
306005870
ADMINISTRATOR/
DIRECTOR:		FAJARDO, RHOENAFACILITY TYPE:
740
ADDRESS:17709 BEECH STREETTELEPHONE:
(949) 413-3049
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 5DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:48 AM
MET WITH:Liezl ParajuliTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by caregiver Marilou Escalona. Lead caregiver staff Liezl Parajuli arrived shortly to assist with the visit and explained the reason for the visit. Administrator Rhoena Fajardo is on vacation. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for four. Currently there are five residents, of which four are on hospice during today's visit.

At around 11:30, LPA Tea reviewed five resident files and two staff files. There were discrepancies noted in the review of staff files. Administrator certificate expires on April 10, 2026. There are no records of required quarterly disaster drills.



LPA Tea along with caregiver toured the facility around 12:06 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a two-story home that consists of 3 resident bedrooms, 2 bathrooms, living room, dining area, kitchen, sunroom and attached garage. The second story is staff only area where residents do not reside at. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms, and they are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 107.6 degrees F and 106.8 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, dressings, tweezers, thermometer, and scissors. Kitchen was inspected. Kitchen appliances are operational during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be locked and inaccessible to clients in care under the kitchen sink and in the garage. The fire extinguisher in the kitchen is fully charged. LPA toured the outside grounds and there is ample seating with shade and the exit

Continuation of annual inspection on LIC809C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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 01/24/2025 04:11 PM - It Cannot Be Edited


Created By: Michael Tea On 01/24/2025 at 03:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANGELIC DWELLING CARE HOME
FACILITY NUMBER: 306005870

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on LPA's review of staff records. There is no annual staff training. This could pose as a potential health and safety risk to residents in care.
POC Due Date: 02/14/2025
Plan of Correction
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Provide proof of 20 hours of annual staff training to LPA by POC due date.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of medication. The centrally stored medication list needs to be updated and documented properly. Expired medication needs to be discarded and noted. This could pose as a potential health and safety risk to residents in care.
POC Due Date: 02/14/2025
Plan of Correction
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Facility will created and organize new monthly centrally stored medication list and provide proof to LPA by POC due date.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/24/2025 04:11 PM - It Cannot Be Edited


Created By: Michael Tea On 01/24/2025 at 03:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANGELIC DWELLING CARE HOME
FACILITY NUMBER: 306005870

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 LPA's review of records. There are no records of quarterly disaster drills. This could pose as a potential health and safety risk to the residents in care.
POC Due Date: 02/14/2025
Plan of Correction
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Facility will conduct disaster drill and document and provide proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANGELIC DWELLING CARE HOME
FACILITY NUMBER: 306005870
VISIT DATE: 01/24/2025
NARRATIVE
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gate on the right side of the facility is self-latching and operational. LPA observed emergency supplies, food and water supply in the garage. Facility provides activities based on resident interests. The residents play card games and bingo, they paint and go outside sometimes. At the time of annual visit, residents were watching television and eating lunch.

LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order but not properly documented. LPAs interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with facility staff and a copy of these reports were given to the facility along with a copy of the LIC 858; 859;809-D, 9102 and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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