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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880544
Report Date: 02/18/2025
Date Signed: 02/18/2025 03:46:49 PM

Document Has Been Signed on 02/18/2025 03:46 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: 6CENSUS: 5DATE:
02/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee, Angela ZhangTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with staff and was later joined by Administrator and Licensee Angela Zhang who were informed of the purpose of the visit. At the time of the visit there was (3) staff and (5) residents present.

The facility is a one story home with (4) bedrooms and (2) bathrooms for residents and (1) staff bedroom. No pools or firearms are being kept at the facility. LPA observed the following:

Infection Control: The LPA observed the facility restrooms and kitchen had hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA did not have an infection control plan at the time of the visit, there a citation is being issued.



Physical Plant: LPA observed the resident bedrooms. Physical plant, floors, windows, and doors were observed and fixtures and furniture were in good were present. The outdoor area was observed to be free of hazards. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational. The hot water temperature was initially read at 110F in a resident restroom. Based on record review Resident #2 (R2) is bedridden and the licensee is approved for non-ambulatory residents only. LPA observed R1's room does only has (1) exit and does not have a side door leading to the emergency route. Therefore, the licensee is being cited for not having the appropriate fire clearance.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 02/18/2025
NARRATIVE
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Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. Required postings were found in the facility. The current administrator provided proof of their Administrator's Certificate. Based on staff interview it was revealed that only (1) staff and (1) volunteer are working at the facility at this time, and (1) administrative staff comes to supervised the staff's work but does not assist with direct care needs. Staff and Licensee revealed there is no awake staff at night, when assistance is needed residents call on the staff. The licensee was interviewed who stated they do assist residents and are present at the facility every day including at night. However, the licensee did not have a staff schedule at the time of the visit to verify the staff schedules. Therefore, the licensee is being cited for not having an up to date staff schedule reflecting coverage at all times.

Record Review and Resident/Staff Files: LPA reviewed (1) staff file and conducted an interview with staff which revealed the training was received from their previous employment. The licensee revealed they would have to document the hours of training provided. The licensee is being cited for not having documentation of staff training.

LPA was unable to review (2) of (3) staff files due to them not being available at the time of the visit. Staff 1 (S1) did not have a file at the time of the visit. The licensee is being sited for not having staff file present for review.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
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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: 02/18/2025
NARRATIVE
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Resident #3 (R3) did not have a SAFEGUARDS FOR PROPERTY/VALUABLES form in their file. Therefore, the licensee is being cited for not having this document at the time of the visit. Resident #4 (R4)'s Needs and Services Plan revealed the licensee is signing as the R5's legal representative. Interview with licensee revealed they had not sent the form to the responsible party for signature and review. Therefore, the licensee is being cited for not having a meeting with the resident's representative.

Health Related Services/ Incidental Medical Services: All resident medications were locked. LPA reviewed resident medication records which revealed medication had required labeling and centrally stored lists for all residents.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The licensee stated they conducted their last fire drill a year ago which did not meet the licensing requirements. Therefore a citation was issued for not having completed a fire drill. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items.

An exit interview was conducted where this report was reviewed along with the deficiency pages and appeal rights.

*LPA was present at the facility from 9:00am to 11:50am, then returned to the facility from 1:10pm to 3:45pm in order to prepare the report.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 02/18/2025 03:46 PM - It Cannot Be Edited


Created By: Janira Arreola On 02/18/2025 at 02:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/18/2025

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 observation, interview, and record review, the licensee did not comply with the section cited above with (1) resident 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.
POC Due Date: 02/19/2025
Plan of Correction
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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 emeregcny exit leading to the exterior of the home and exit route. Proof to be submitted by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


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Document Has Been Signed on 02/18/2025 03:46 PM - It Cannot Be Edited


Created By: Janira Arreola On 02/18/2025 at 02:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)(1)(C)
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. (1) The Infection Control Plan shall include all of the following: (C) An Infection Control Training Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above due to no infection control plan being retained at the facility during the time of the visit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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The licensee agreed to submit their infection control plan by the POC due date. The Licensee agreed send a self certified statement appointing a new administrtor that will help audit the facility files and ensure all files are complete at the facility. The POC is due by the due date.
Type B
Section Cited
CCR
87218(a)(1)
Theft and Loss
(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (1) The initial personal property inventory shall be completed by the licensee and the resident or the resident's representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with (1) resident who did not have a personal property form in their file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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The licensee agreed to document the form with the residents and submit to the LPA by the POS due date. The licensee agreed to appoint a new administrator have them audit resident files for completion. The POC is due by the 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.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 02/18/2025 03:46 PM - It Cannot Be Edited


Created By: Janira Arreola On 02/18/2025 at 02:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/18/2025

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
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Based on interview there was no staff files for (1) staff, and incomplete file for (2) staff. This poses a potential health saftey or personal rights risk to clients in care.
POC Due Date: 02/25/2025
Plan of Correction
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The licensee agreed to submit the complete staff files to the LPA and apoint a new administrator to audit the staff files for completion. The POC is due by the POC due date.
Type B
Section Cited
CCR
87412(e)
Personnel Records
(e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above there was no personnel record retained at the facility at the time of the visit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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The Licensee agreed to provide the LPA a staff schedule showing staff coverage at all times. The POC is due by the 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.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 02/18/2025 03:46 PM - It Cannot Be Edited


Created By: Janira Arreola On 02/18/2025 at 02:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(6)
Personnel Requirements - General
(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in with staff not having documented training in their file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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The licensee agreed to send the LPA a copy of the staff training conducted at the facility. Proof to be submitted by the POC due date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 02/18/2025 03:46 PM - It Cannot Be Edited


Created By: Janira Arreola On 02/18/2025 at 02:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on interview and record review, the licensee did not comply with the section cited above with (1) of (5) resident who did not have a care plan signed by their representative which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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The licensee agreed to meet with the representative and have the needs and services plan signed for the resident. Proof is due by the POC 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.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 02/18/2025 03:46 PM - It Cannot Be Edited


Created By: Janira Arreola On 02/18/2025 at 02:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above by not conducting a fire drill within the required time frame which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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2
3
4
The licensee agreed to conduct a fire drill and submit documentation according to the regulation cited above. This is due by the POC due date.
Type B
Section Cited
CCR
87705(b)(2)
Care of Persons with Dementia
(b) Licensees shall be responsible for the following: (2)For facilities with fewer than 16 residents, ensuring there is 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 in addition to requirements specified in Section 87415, Night Supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above by not having awake staff at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
1
2
3
4
The licensee agreed to submit a staff schedule showing coverage from 10pm to 6am every day. This is due by the 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.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
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