331800082-11-18-2024-56-AS-MBRN-DB62K7-20241118162730

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800082
Report Date: 11/18/2024
Date Signed: 11/18/2024 04:27:47 PM

Document Has Been Signed on 11/18/2024 04:27 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 MANOR		FACILITY NUMBER:	331800082
ADMINISTRATOR/ DIRECTOR:	MATAMOROS, MICHELLE		FACILITY TYPE:	740
ADDRESS:	35490 PRAIRIE ROAD		TELEPHONE:	(951) 609-1646
CITY:	WILDOMAR	STATE: CA	ZIP CODE:	92595
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	11/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:12 PM
MET WITH:	Licensee/Administrator Michelle Matamoros		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/18/2024 at 12:12 PM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a Staff #2 (S2) and was granted entry to the facility. At the time of the visit there was one (1) staff present, and five (5) residents present. Licensee/Administrator Michelle Matamoros was contacted and informed of the visit. Licensee/Administrator Matamoros arrived during the visit. LPA Brown explained the purpose of the visit to LIcensee/Administrator Matamoros. The facility is a five (5) bedroom, two (2) bathroom home with a kitchen, dining area, living room, and an attached garage. The facility is a Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents and two (2) resident may be bedridden. The facility's approved for four (4) Hospice Waiver. The current census is five (5) residents. LPA Brown was accompanied by Licensee/Administrator Matamoros and S2 to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA Brown 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 Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperature in the residents/staffs shared bathroom to be at 113.9 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCLD complaint poster, ombudsman poster, labor laws and the disaster plan were posted in a common area. Cleaning supplies, toxins were kept inaccessible to residents in care. There was a designated storage space for resident/staff files.*Continuation in LIC809C*

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

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 8

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: 11/18/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Medications are kept inside the medication cabinet in the hallway inaccessible to residents. Overall, the facility is clean, in good repair for residents in care. During the tour of the facility, LPA Brown observed Resident #3 (R3) has a full bed rail but per documents review and staff interview, R3 is not on hospice and there's no letter submitted to CCLD and approved by CCLD for the full bed rail. Deficiency will be issued. Moreover, LPA Brown observed two (2) sharp metal skewers in the kitchen drawer, not locked and accessible to residents in care. Deficiency will be issued.

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility.

Care & Supervision: LPA Brown observed that there's no staff scheduled to work the night shift, as required for facility with dementia residents. Deficiency will be issued.

Record Review: LPA Brown did not observe Infection Control Plan maintained at the facility. Deficiency will be issued. LPA reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals, needs and services plans, centrally stored medication list. LPA Brown observed Resident #2 (R2), Resident #3 (R3) do not have the required Pre-Admission Appraisal in their facility file. Deficiency will be issued. Also, LPA Brown observed no Appraisal Needs and Services Plan for Resident #2 (R2) and Resident #3 (R3). Deficiency will be issued.

LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown observed Staff #2 (S2) does not have the required Health Screening/Medical Assessment in S2 personnel file. Deficiency will be issued. LPA Brown observed Staff #2 (S2), Staff #3 (S3) do not have the required 20 hours training annually. Deficiency will be issued. LPA Brown observed Staff #2 (S2) and Staff #3 (S3) do not have the required 10 hours of initial training maintained in their facility file. Deficiency will be issued.

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

An exit interview was conducted, and this report (LIC809), LIC809D, LIC9102 and Appeal Rights were discussed and provided to Licensee/Administrator Michelle Matamoros.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

Page: 2 of 8

Document Has Been Signed on 11/18/2024 04:27 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: ANGELIC MANOR	FACILITY NUMBER: 331800082
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #2 (S2) completed the required Health Screening Report which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit S2 medical appointment to complete the required Health Screening Report to LPA Brown on Plan of Correction (POC) due date.

Section Cited

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring Staff #2 (S2) and Staff #3 (S3) complete the required 10 hours of Initial Training which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on HSC1569.69(a)(2) and submit proof to LPA Brown on Plan of Correction (POC) due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

Page: 3 of 8

Document Has Been Signed on 11/18/2024 04:27 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: ANGELIC MANOR	FACILITY NUMBER: 331800082
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above allowing Resident #3 (R3) to have full bed rail and R3's not on hospice and no letter was submitted to CCLD for approval for the full bed rail which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2024
	Plan of Correction
1 2 3 4	Licensee removed R3 full bed rail during the visit. Plan of Correction (POC) cleared.

Section Cited

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not scheduling a staff to work the night shift, awake and on duty as required for facility with dementia residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit an updated Peronnel Report (LIC500) showing a staff scheduled to work the night shift to LPA Brown on POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

Page: 4 of 8

Document Has Been Signed on 11/18/2024 04:27 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: ANGELIC MANOR	FACILITY NUMBER: 331800082
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record revie], the licensee did not comply with the section cited above by not developing the required Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/25/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit a copy of the required Infection Control Plan to LPA Brown on Plan of Correction (POC) due date.

Section Cited

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not esuring that Staff #2 (S2) and Staff #3 (S3) complete the required 20 hours training annually which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/25/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit proof of S2 and S3 completed 20 hours annual training to LPA Brown on POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

Page: 5 of 8

Document Has Been Signed on 11/18/2024 04:27 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: ANGELIC MANOR	FACILITY NUMBER: 331800082
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #2 (R2) and Resident #3 (R3) have their Pre-Admission Appraisal in their facility file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/25/2024
	Plan of Correction
1 2 3 4	Licensee stated to complete R2 and R3 Pre-Admission Appraisal and submit copies to LPA Brown on Plan of Correction (POC) due date.

Section Cited

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #2 (R2) and Resident #3 (R3) have their Pre-palcement Needs & Services Plan in their facility file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/25/2024
	Plan of Correction
1 2 3 4	Licensee stated to complete and submit copies of R1 and R3 Pre-palcement Needs and Services Plan to LPA Brown on POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

Page: 6 of 8

Document Has Been Signed on 11/18/2024 04:27 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: ANGELIC MANOR	FACILITY NUMBER: 331800082
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87705 Care of Persons with Dementia (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	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #1 (R1) has an annual medical assessment as required for resident with dementia which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit R1 medical appointment to complete the required annual medical assessment to LPA Brown on Plan of Correction (POC) due date.

Section Cited

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the two (2) sharp metal skewers were locked and not accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87705(f)(1) and submit proof of staff training log to LPA Brown on POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

Page: 8 of 8