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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800082
Report Date: 03/01/2022
Date Signed: 03/01/2022 10:34:46 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2020 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200910090735
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: 5DATE:
03/01/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Michelle Matamoros, AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility staff are restraining residents
INVESTIGATION FINDINGS:
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This unannounced visit conducted by Amy Goldenberg and Ryan Gardner, Licensing Program Analysts (LPAs), is being conducted to conclude this agency's investigation into the above-mentioned complaint allegation.

During the course of this investigation LPAs interviewed two (2) staff, collected pictures of restraints used in the facility, and reviewed one resident record (R1).

It is alleged that the facility is using restraints on residents. LPA learned the following information through interview of the facility Administrator: The administrator admits that the facility utilized a gait belt to assist R1. The purpose for the use of the belt was disclosed for prevention of falling. The belt was used on R1's lap and tied in the back of the chair loosly. R1 did not have an order for the use of any restraint or gait belt according to staff interviewed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
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 18-AS-20200910090735
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 MANOR
FACILITY NUMBER: 331800082
VISIT DATE: 03/01/2022
NARRATIVE
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Based on the available information, a preponderance of the evidence supports that a violation has occurred. We have substantiated the complaint allegation.

A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20200910090735
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 MANOR
FACILITY NUMBER: 331800082
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2022
Section Cited
CCR
87608(1)(3)
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Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance... rather than restrict movement...
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Administrator agrees to review the regulation cited for postural support as well as regulations pertaining to personal rights. Administrator to submit statement of understanding of regulations reviewed by POC due date.
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A written order from a physician indicating the need for the postural support... The facility did not meet this requirement as evidenced by failure to obtain a physician's order for the postural support used. This poses a risk to the health and safety of residents in care.
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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: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3