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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880544
Report Date: 04/17/2025
Date Signed: 04/17/2025 02:01:38 PM

Document Has Been Signed on 04/17/2025 02:01 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:		VICTOR OTUYAFACILITY TYPE:
740
ADDRESS:13247 SUNBIRD DRTELEPHONE:
(951) 653-0652
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 5DATE:
04/17/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Licensee, Angela ZhangTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility to conduct a Plan of Correction (POC) visit. LPA met with Licensee, Angela Zhang who was informed of the purpose of the visit. LPA conducted interviews, records review, and a walk through of the home.

The following POCs were met during or before the time of the visit and cleared during the visit:

On 3/20/2025, LPA issued a citation for 87202(a) Fire Clearance for bedridden resident which the facility is not approved for. The POC was for the licensee to submit a request for a bedridden fire clearance by the POC due date of 3/21/2025. On 3/21/2025 the regional office received the application for the fire clearance. LPA checked on the bedridden resident during the visit and observed the resident is located in a room with a second exit door. Therefore, the POC has been met and a clearance letter was provided at the time of the visit.

On 2/18/2025 LPA issued citation for 87467(a)(3) Resident Participation in Decision making for (1) resident’s whose care plan was signed by the Licensee twice, once for the licensee and once for the resident’s responsible party.

NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/17/2025 02:01 PM - It Cannot Be Edited


Created By: Janira Arreola On 04/17/2025 at 01:19 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: 04/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2025
Section Cited
CCR
87470(c)(1)(C)

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(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:
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The licensee agreed to fill out the courtsey form on file and send the LPA the comcpleted form by the POC due date.
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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.
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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 Danielson
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2025


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: 04/17/2025
NARRATIVE
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Interview and record review revealed the Licensee is not the resident’s responsible party and the Licensee did not send the care plan to the responsible party for review. POC was for the Licensee to send the care plan to the responsible party by POC due date 2/25/2025, On 2/23/2025 the licensee submitted proof to the LPA of submitting the care plan to the resident’s representative for review and signature. Therefore, the POC has been met and the licensee was issued a clearance letter at the time of the visit.

87412(a) Personnel Records was cited for incomplete and unavailable staff files for licensing to review. 87411(c)(6) Personnel Requirements – General was also cited for lack of documented staff training. The POC was for the Licensee to submit the complete staff files to the LPA and appoint a new administrator to audit the staff files for completion. LPA received an email appointing new administrator Victor Otuya. During the visit, LPA reviewed staff training conducted. Therefore, the POC has been met and the deficiency was cleared.

On 3/26/2025 LPA received notification appointing VICTOR OTUYA as the new administrator but did not receive a copy of the completed staff files. The LPA needs to review LIC501, Administrator’s Certificate, first aid and CPR training for the Licensee. 40-hour annual training, LIC501, TB test and physical need to be submitted for Staff #1 (S1) and Staff #2 (S2). S2’s medication training also needs to be submitted. During today’s visit LPA conducted file review and reviewed Licensee's, S1, and S2's file and documents listed above. Therefore, the POC has been met and the deficiency was cleared for staff records.

87412(e) Personnel Records was cited for the licensee not having an LIC500 showing staff coverage. 87705(b)(2) Care of Persons with Dementia was also cited as staff interviews revealed there is no awake staff at night despite residents being diagnosed with Dementia in the home. The POC was for the licensee to submit an LIC500 showing staff coverage at all times, and awake staff at night. The licensee submitted a completed LIC500 to the LPA on 3/24/2025. Therefore, the POC has been met and the deficiency was cleared.

NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
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: 04/17/2025
NARRATIVE
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The following POC was previously agreed upon and the POC due date has passed:

On 2/18/2025 LPA conducted an annual visit and cited deficiencies. The POC due date and date for addressing the POC has passed. Therefore, the deficiency is being recited with new POC due date. The following are the previously cited item:

87470(c)(1)(C) Infection Control Requirements was cited for not having an infection control plan for licensing review. The POC was for the licensee to submit their infection control plan. The Licensee also agreed to send a self certified statement appointing a new administrator that will help audit the facility files and ensure all files are complete at the facility by the POC due date.

On 3/26/2025 LPA received notification appointing VICTOR OTUYA as the new administrator but did not submit a self certified statement from the Licensee. LPA has also not received the facility’s infection control plan. On today’s visit LPA spoke with Licensee who showed the LPA the infection control plan they had on file. The plan was not filed out. The licensee stated they could fill out and send to LPA by POC due date. Therefore, the facility still does not have an infection control plan for licensing to review. The deficiencies is being recited and a new POC due date was issued.

An exit interview was conducted where a copy of this report, deficiency pages, and clearance letters were reviewed and provided.

NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC809 (FAS) - (06/04)
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