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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005870
Report Date: 04/02/2024
Date Signed: 04/02/2024 12:38:32 PM


Document Has Been Signed on 04/02/2024 12:38 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ANGELIC DWELLING CARE HOMEFACILITY NUMBER:
306005870
ADMINISTRATOR:FAJARDO, RHOENAFACILITY TYPE:
740
ADDRESS:17709 BEECH STREETTELEPHONE:
(949) 413-3049
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 4DATE:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rhoena Fajardo, Licensee/AdministratorTIME COMPLETED:
12:42 PM
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 On today's date, Licensing Program Analysts (LPAs) LPA Rosie Quiroz and LPA Michael Tea conducted an unannounced visit for the purpose of conducting a required Annual inspection. LPAs were greeted and granted entry into the facility by Caregiver 1 (CG1). LPAs met with Licensee/Administrator (L/AD) Rhoena Fajardo and discussed purpose of today's visit.
This is a a Residential Care Facility for the Elderly, licensed to provide services to age range 60 and over, approved for capacity of (6) six Non-Ambulatory residents and has a Hospice waiver approved for 4 hospice residents. There are currently four (4) residents in care at this time, of which (1) one is receiving hospice care services. There are no active COVID-19 cases in the facility at this time.
AD Rhoena Fajardo has an Administrator certificate with expiration date of April 10, 2024. AD Rhoena Fajardo indicated currently in process of renewing Administrator certificate, and agreed to submit copy of renewal to Community Care Licensing upon completion.
LPAs along with (AD) Fajardo toured the interior and exterior of the facility. During today's inspection tour, LPAs observed 3 of 4 Residents in the living room with staff supervision and 1 of 4 residents in their bedroom. LPA Quiroz interacted and interviewed with Caregiver and 4 of 4 residents during today's visit.
LPAs nspected resident's bedrooms and bathrooms. The water temperature in resident's bathrooms were recorded to be between 105.3 and 105.4 degrees Fahrenheit. LPAs inspected resident's bedrooms and appeared to be clean. Facility temperature in resident's bedrooms and throughout the facility was recorded to be within normal limits. LPAs observed the emergency and disaster and evacuation plan. Facility has supply of emergency food, water and PPE in the garage area readily available for staff and residents in care. Fire extinguisher observed last serviced on November 14, 2023. LPAs observed functional and operational washer and dryer in the garage area. Medications, sharps and disinfectants were observed to be locked and secured. LPAs toured the outside of the facility and observed seating and shaded area in the backyard for residents and visitor's enjoyment. (SEE LIC 9102-TV)
LPAs reviewed 4 of 4 resident records and 4 of 4 personnel files.
CONTINUED ON LIC 809-C PAGE...
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANGELIC DWELLING CARE HOME
FACILITY NUMBER: 306005870
VISIT DATE: 04/02/2024
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CONTINUED...
While conducting resident records review for Resident 1 (R1), LPAs observed LIC 602- Physician report for Resident 1 dated 11/22/2022. (SEE LIC 809-D). While reviewing centrally stored medications for Resident 4, LPAs observed two medications and 2 supplement medications not listed on Medication Administration Records. This was verified with L/AD Fajardo (SEE LIC 809-D)

Citations and Technical Violations issued during today's visit.

During today's visit, LPAs provided Consultation on Title 22 and Infection control. An exit interview was conducted with (L/AD) Rhoena Fajardo, and a copy of this report, LIC 809-D pages, LIC 9102 Technical Violation, Appeal Rights, LIC 858- Client/Resident's records review and LIC 859- Staff Records Review were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/02/2024 12:38 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, 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: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(d)
CARE OF PERSONS WITH DEMENTIA 87705(d): Each resident with dementia shall have a annual medical assessment as specified in section 87458, medical assessment, and reappraisal done atleast annually, both of which shall include a reassessment of the resident dementia care needs.

This requirement is not met as evidenced by: LPAs observed LIC 602 for resident 1 dated 11/22/2022, R1 has a diagnose of dementia.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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L/AD Rhoena Fajardo will obtain copy of R1's updated physician report and submit to CCLD by POC due date of 4/5/2024.
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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 04/02/2024 12:38 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, 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: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
INCIDENTAL MEDICAL AND DENTAL CARE 87465(e): For every prescription and non prescription, PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the resident's file, and a label on the medication...
This requirement is not met as evidenced by: During today's visit, LPAs observed 2 supplemental vitamins and 2 medications in centrally stored medications not listed on Resident 4's Medication Administration Record.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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L/AD Rhoena Fajardo will read and understand CCR 87465, and obtained updated MAR's for Residents in care and submit to CCLD by 4/5/2024.
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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
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