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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800082
Report Date: 11/19/2021
Date Signed: 11/19/2021 11:36:55 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ANGELIC MANORFACILITY NUMBER:
331800082
ADMINISTRATOR:MATAMOROS, MICHELLEFACILITY TYPE:
740
ADDRESS:35490 PRAIRIE ROADTELEPHONE:
(951) 609-1646
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY:6CENSUS: 4DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Amilia TalamanteTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Jennifer Semin arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility via telephone. LPA met with Caregiver Amilia Talamante. Licensee/Administrator Michele Matamoros was contacted and was present via telephone. LPA advised Ms.Talamante of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only.
LPA went over COVID-19 best practices for infection control and prevention with Ms. Talamante who is successfully incorporating the facility's Mitigation Plan. Residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA observed the facility to be missing some of the recommended postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing. LPA will be issuing a Technical Assistance Advisory Note. LPA will provide these signs to licensee. Ms. Talamante stated emergency contact information for local fire department has been updated.
LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located at the central entry point for convenience. LPA determined facility is is need of acquiring additional PPE for on hand stock. LPA will be issuing a Technical Assistance Advisory Note. Licensee placed an order while LPA was present.
LPA and Ms. Talamante discussed creating a box, or similar, to have a supply of PPE ready that would be dedicated for isolation room, along with a trash can to put inside and outside of an isolation room.
LPA inquired as to if staff have been fit tested for N95 masks, and Ms. Talamante stated their staff have not been fit tested yet. LPA will be issuing a Technical Assistance Advisory Note. Additionally, residents and staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19.
An exit interview was conducted, and this report and LIC9102 TA Advisory Notes were discussed and provided to Ms. Talamante.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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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