331880544-12-31-2024-18-AS-JARA-DCGPN7-20241231102728

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880544
Report Date: 12/31/2024
Date Signed: 12/31/2024 10:28:23 AM

Document Has Been Signed on 12/31/2024 10:28 AM - 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/ DIRECTOR:	ANGELA ZHANG		FACILITY TYPE:	740
ADDRESS:	13247 SUNBIRD DR		TELEPHONE:	(951) 653-0652
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/31/2024
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:28 AM
MET WITH:	Licensee, Angela Zhang		TIME VISIT/ INSPECTION COMPLETED:	10:35 AM

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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced Plan of Correction (POC) Visit. LPA met with, Licensee, Angela Zhang, who was informed of the purpose of the visit.

The following POC’s were cleared at the time of the visit:

On visit date 12/04/2024, deficiency was cited for 87303(e)(2) Maintenance and Operation. Based on observation the water temperature in the facility restrooms read 122F and 125F. This posed a potential health, safety, or personal rights risk to residents in care. The POC was to adjust the water temperature to the required range. The licensee agreed to send proof of the required temperature by the POC due date of 12/13/2024.

On the POC due date, LPA received photos of the hot water temperature in the master bathroom reading at 110F. LPA did not receive photos of the common restroom. On today’s visit LPA tested the hot water temperature in both bathrooms which revealed the common restroom sink has a hot water temperature of 116F and the master bathroom shower has a hot water temperature of 105.2F.

Therefore, the POC has been met and the POC was cleared at the time of the visit. A clearance letter was provided to the licensee.

Tricia Danielson	TELEPHONE: (951) 202-5067
Janira Arreola	TELEPHONE: 951-233-6759
	DATE: 12/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024

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: 12/31/2024

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The following POC’s were not cleared at the time of the visit and Civil Penalties are being assessed:

On visit date 12/04/2024, deficiency was cited for 87468.2(a)(1) Additional Personal Rights of Residents in Privately Operated Facilities. Based on interview and observation, the private shower in the master bathroom was being used by all staff and residents due to the common restroom having a faulty shower faucet, This posed a potential personal rights, health, or safety risk to residents in care. The POC was to fix the common shower of the facility and inform the LPA when the repairs are completed in order to provide privacy to residents in the shower and in their private bedroom and ensure the facility is in good repair. The licensee agreed to send proof of the POC by the due date of 12/27/2024.

LPA observed the common shower is only delivering cold water due to the repairs not being completed on the faucet. Based on staff and resident interviews, staff and residents are currently using the master bathroom shower only. Therefore, the POC has not been met and was assessed civil penalties for failure to correct. Civil penalties are being assessed from 12/28/2024 to 12/31/2024 at $100 per day. The licensee was advised that civil penalties will continue to accrue until the POC is met.

An exit interview was conducted where this report was reviewed and provided.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024

LIC809 (FAS) - (06/04)

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