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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800082
Report Date: 10/12/2022
Date Signed: 10/12/2022 03:03:40 PM


Document Has Been Signed on 10/12/2022 03:03 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, 1650 SPRUCE ST STE 200 MS29-27
, 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: 5DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Michelle Matamoros- AdminstratorTIME COMPLETED:
03:13 PM
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic.

LPA Gardner met with Administrator Michelle Matamoros and was granted entry to the facility. At the time of the visit there were two (2) staff, and five (5) residents present.

LPA Gardner toured the facility inside and out and went over COVID-19 best practices for infection control and prevention with Michelle Matamoros. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining residents and properly caring for residents with COVID-19 positive results and/or exposures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The entrance of the facility has a check in process for visitors that includes a temperature check and a symptom check. The residents have hand sanitizer available to them throughout the facility, and the bathrooms were stocked with hand soap and paper towels. The facility has postings throughout the facility for proper cough etiquette, proper hand washing procedure, and/or social distancing guidelines. LPA Gardner requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in the garage. The facility was notified they need to obtain a full thirty (30) day supply of surgical masks. The facility has a supply of PPE items such as gloves, face shields, gowns, N95 masks, disinfectant, and hand sanitizer. The facility will be issued a Technical Advisory Note for not having a full thirty (30) day supply of surgical masks.

All residents and staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ANGELIC MANOR
FACILITY NUMBER: 331800082
VISIT DATE: 10/12/2022
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Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) and LIC9102 were discussed and provided Administrator Michelle Matamoros.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC809 (FAS) - (06/04)
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