331800082-12-27-2023-56-AS-RGAR-CYWTD6-20231227133749

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800082
Report Date: 12/27/2023
Date Signed: 12/27/2023 01:37:55 PM

Document Has Been Signed on 12/27/2023 01:37 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ANGELIC MANOR		FACILITY NUMBER:	331800082
ADMINISTRATOR:	MATAMOROS, MICHELLE		FACILITY TYPE:	740
ADDRESS:	35490 PRAIRIE ROAD		TELEPHONE:	(951) 609-1646
CITY:	WILDOMAR	STATE: CA	ZIP CODE:	92595
CAPACITY:	6	CENSUS: 6	DATE:	12/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:17 AM
MET WITH:	Michelle Matamoros- Administrator		TIME COMPLETED:	01:48 PM

NARRATIVE

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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 comprehensive annual inspection. LPA met with Administrator Michelle Matamoros and was granted entry to the facility.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory residents, two (2) residents may be bedridden. The current census is six (6) residents. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following:

The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the bathrooms to be at 120 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident and staff files. Medications are kept inside the hallway cabinet inaccessible to residents. Non-perishable and perishable food supply is sufficient for the residents in care. Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

LPA reviewed six (6) residents files for admission agreements, updated physician reports, and needs and services plans. LPA found that Resident’s R1, R2, and R3 have a condition that requires an annual updated physician report. R1’s physician report is dated 4/28/2022. R2’s physician report is dated 8/29/2019. R3’s physician report is dated 10/29/2020. The facility will be issued a deficiency for not having updated physician reports for the residents.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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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Document Has Been Signed on 12/27/2023 01:37 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGELIC MANOR	FACILITY NUMBER: 331800082
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by interview, document review, and observation, the licensee did not comply with the section cited above evidenced by not having a staff file for staff S1 which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87412 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to create a staff file for S1 and store the file at the facility by the POC due date. POC is due by 12/29/2023.

Type B

Section Cited

CCR

87705(c)(5)

(c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having an annual medical assessment completed for Resident’s R1, R2, and R3 which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 01/31/2024
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87705 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to have updated medical assessments completed for R1, R2, and R3 by the POC due date. POC is due by 1/31/2024.

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: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGELIC MANOR	FACILITY NUMBER: 331800082
	VISIT DATE: 12/27/2023

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LPA reviewed six (6) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings. LPA found that Staff S1 does not have a staff file at the facility. The facility will be issued a deficiency for not having a staff file for S1.

Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D, and LIC811 were discussed and provided to Administrator Michelle Matamoros, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

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