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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880544
Report Date: 03/20/2025
Date Signed: 03/20/2025 12:30:47 PM

Document Has Been Signed on 03/20/2025 12:30 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ANGELA'S CARE HOMEFACILITY NUMBER:
331880544
ADMINISTRATOR/
DIRECTOR:		ANGELA ZHANGFACILITY TYPE:
740
ADDRESS:13247 SUNBIRD DRTELEPHONE:
(951) 653-0652
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
03/20/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:01 AM
MET WITH:Licensee, Angela ZhangTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analysts (LPA)’s Janira Arreola and Seo Jeon, conducted an unannounced visit to the facility to conduct a Plan of Correction (POC) Visit. The purpose of this report is to document the POCs that were previously agreed upon and which the POC due dates have passed. LPAs met with Licensee, Angela Zhang who was informed of the purpose of the visit. LPAs conducted a walk through, conducted interviews, and records review. There were (2) staff and (6) residents present during the visit.

During Annual Visit conducted on 02/18/2025 the facility was cited for California Code of Regulations (CCR) Section 87202(a)(2) for Resident #1 (R1) who is bedridden, while the facility is not approved for bedridden residents by the local fire jurisdiction. The POC was to call the fire department, place R1 in a room with a second exit door, and apply for a bedridden clearance and submit by the POC due date of 02/19/2025.



On 02/18/2025, LPA observed the licensee called the fire department and alerted them on the bedridden resident. During today's visit LPAs conducted a health and safety check on R1 and observed they are in a room with a second exit door. Interview with the licensee and record review revealed the licensee has not submitted the request for bedridden fire clearance.

Therefore, the POC has not been met. The POC is being recited and a new POC due date was issued. An exit interview was conducted with Licensee Angela Zhang where this report was reviewed and provided.
Tricia DanielsonTELEPHONE: (951) 202-5067
Janira ArreolaTELEPHONE: 951-233-6759
DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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 03/20/2025 12:30 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ANGELA'S CARE HOME
FACILITY NUMBER: 331880544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2025
Section Cited
CCR
87202(a)(2)

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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons. This requirement is not met as evidenced by:
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The licensee called the fire department during the time of the visit to notify of the bedridden resident, and agreed to submit a request for a bedridden fire clearance. The licensee agreed to move the resident to a room with an emeregency exit leading to the exterior of the home and exit route. Proof to be submitted by the POC due date.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above with R1 who is bedridden. The licensee is not approved for bedridden clearance which poses an immediate health, safety or personal rights risk to persons 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.
Tricia DanielsonTELEPHONE: (951) 202-5067
Janira ArreolaTELEPHONE: 951-233-6759

DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025

LIC809 (FAS) - (06/04)
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