331880544-3-27-2024-18-AS-CCON-D3RUTY-20240327155243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880544
Report Date: 03/27/2024
Date Signed: 03/27/2024 03:52:53 PM

Document Has Been Signed on 03/27/2024 03:52 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 HOME		FACILITY NUMBER:	331880544
ADMINISTRATOR:	ANGELA ZHANG		FACILITY TYPE:	740
ADDRESS:	13247 SUNBIRD DR		TELEPHONE:	9516530652
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY:	6	CENSUS: 4	DATE:	03/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Higinio Alvarez - Caregiver		TIME COMPLETED:	04:15 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	Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with staff Higinio Alvarez and informed him of the purpose of today's inspection. Below is a summary of what was observed: Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include: soap and paper towels at hand washing stations and hand washing guides posted. Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 100.9 degrees. Deficiency cited. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives were locked away from residents' reach in a drawer in the kitchen. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. LPA Colvin observed a latch on the refrigerator which is capable of holding a lock to secure the refrigerator. Since LPA Colvin did not observe a lock on the latch, LPA Colvin is only issuing a Technical Assistance Advisory Note, recommending the facility to remove the latch. Planned Activities: LPA Colvin observed the facility's Activity Calendar as well as residents engaging in their own private activities in their rooms. Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file with the Department, though staff present at the facility could not locate the file in the facility.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

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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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
	VISIT DATE: 03/27/2024

NARRATIVE

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Operational Requirements: The facility is licensed for 6 non-ambulatory residents and has a hospice waiver for up to 3 residents. LPA Colvin observed through review of the resident files that one resident (R1) is bedridden. The facility does not have bedridden fire clearance. Deficiency cited. Violations of the facility's fire clearance is considered a serious violation and is subject to an immediate $500 civil penalty, which LPA Colvin will be assessing today.

Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that the facility has an Administrator with a current Administrator Certificate, though Licensing has not completed processing to update the Change of Administrator. LPA Colvin additionally observed that the acting Administration, Aurora Cuasay, is not associated to the facility. Deficiency cited. When there is a violation of criminal background clearance (such as staff not being associated), a civil penalty is assessed in the amount of $100 per day, per staff member, with a limit of $500 per staff member being assessed, unless the facility has repeated this violation in the last 12 months. Aurora Cuasay has been acting Administrator for the facility since late 2023, so LPA Colvin will be issuing $500 in civil penalties ($100 a day x 5). LPA Colvin additionally observed that at least one direct care staff (S1) does not have current CPR/First Aid Certification, as there's expired in 2023. Deficiency cited. LPA Colvin was unable to verify staff training as staff files were not available to LPA Colvin during today's inspection. Deficiency cited.

Resident Records: LPA Colvin reviewed the files for all 4 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. Resident files appeared to be complete and up to date.

Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet in the kitchen and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions.

An exit interview was conducted with staff Higinio Alvarez (and Administrator Aurora Cuasay via telephone) and a copy of this report, LIC809D, LIC421BG, LIC421IMs, LIC9102, LIC9098 Proof of Corrections, and appeal rights were provided.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2024 03:52 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: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(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:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 of 4 residents (R1) which poses an immediate safety risk to persons in care. LPA Colvin observed that according to R1's file, R1 is bedridden. The facility does not have a fire clearance for bedridden residents.
	POC Due Date: 03/28/2024
	Plan of Correction
1 2 3 4	Administrator is going to obtain a new Physician's Report for R1, showing R1 are non-ambulatory. If this this is not the case, Administrator to speak with Licensee about possibly requesting a change of ambulatory status for the facility to see if they can be approved for bedridden residents, otherwise, R1 will need to be relocated. Administrator to provide LPA Colvin with update on plan for R1/facility's application for bedridden clearance by POC date of 3/28/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2024 03:52 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: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 staff member (acting Administrator) which poses an immediate safety risk to persons in care. LPA Colvin observed that Acting Administrator Aurora Cuasay is not associated to the facility.
	POC Due Date: 03/28/2024
	Plan of Correction
1 2 3 4	Administrator agrees to contact Licensee to have Administrator associated to facility. Administrator may self-certify to LPA Colvin once the association has been completed. Due by Plan of Correction date of 3/28/24.

Type A

Section Cited

CCR

87412(g)(1)

Personnel Records: (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. (1) The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency at the facility as specified in Section 87412(f). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 of 3 staff files, which poses an immediate health, safety or personal rights risk to persons in care. LPA Colvin observed that there were no staff files present for either the two staff present during today's inspection or for the Acting Administrator.
	POC Due Date: 03/28/2024
	Plan of Correction
1 2 3 4	Administrator agrees to develop a plan to ensure staff files are accessible to Licensing upon request and without notice. Administrator to provide LPA Colvin with plan by Plan of Correction date of 3/28/24.

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: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 03/27/2024 03:52 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: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(C)(1)

Personnel Requirements – General: (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 of 3 staff (S1) which poses a potential health risk to persons in care. LPA Colvin observed that S1's CPR Certification is expired.
	POC Due Date: 04/10/2024
	Plan of Correction
1 2 3 4	Administrator agrees to have S1 re-certify for CPR/First Aid and provide LPA Colvin with a copy of the new Certification by the Plan of Correction date of 4/10/24.

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 of 2 resident bathrooms, which poses a potential health or personal rights risk to persons in care. LPA Colvin observed that the hot water in the resident bathrooms was measuring at 100.9 degrees.
	POC Due Date: 04/10/2024
	Plan of Correction
1 2 3 4	Administrator agrees to adjust hot water to ensure it is between 105 - 120 degrees. Administrator to test hot water and provide LPA Colvin with the new measurement by the Plan of Correction Date of 4/10/24.

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: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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