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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880544
Report Date: 07/08/2025
Date Signed: 07/08/2025 03:52:30 PM

Document Has Been Signed on 07/08/2025 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 HOMEFACILITY NUMBER:
331880544
ADMINISTRATOR/
DIRECTOR:		VICTOR OTUYAFACILITY TYPE:
740
ADDRESS:13247 SUNBIRD DRTELEPHONE:
(951) 653-0652
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 2DATE:
07/08/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Staff, Susan OuithuyseTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Anaylts (LPA) Janira Arreola conducted an unannounced visit to the facility LPA initally met with a caregiver Staff, Susan Ouithuyse and spoke with licensee Angela Zhang over the phone who were informed of the purpose of the visit.

LPA met with Staff #1 (S1) upon arrival to the facility. S1 expressed they had just started working at the facility today and were the only staff present at the facility. Additionally on 06/26/2025 the licensee e-mailed the LPA copies of the new administrator Staff #2 (S2), and the new facility manager Staff #3 (S3)'s identification cards. LPA reviewed the Guardian roster of fingerprinted and associated staff and found S1, S2 and S3 have fingerprint clearance but are not associated to the facility. During the time of the visit, S2 the new administrator provided the transfer sheet LIC9182 form for S1. Interview with S2 revealed S2 and S3 have been working at the facility since 06/29/2025. Therefore the facility is being cited for S2 and S3 not being associated to the facility. A civil penalty in the amount of $100 per day for the maximum of (5) days is being issued.

LPA observed (2) residents at the time of the visit. (1) resident is currently bedridden and the facility does not have a bedridden fire clearance. Therefore, the facility is being cited for fire clearance. This violation warrants an immediate $500 civil penalty.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2025
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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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: 07/08/2025
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(3) residents observed during visit on 06/11/2025 were observed to no longer be residing at the facility. LPA was informed that Resident #1 (R1) passed away around (1) month ago. The licensee could not recall if they submitted an incident report for R1. A review of incident reports submitted to the regional office and revealed none for R1. Therefore, the facility was cited for not following reporting requirements for resident deaths within (7) days.

LPA conducted interview with (1) confidential witness who revealed that they were informed the facility had changed ownership. LPA conducted interview with (3) staff which revealed conflicting information. Upon arrival to the facility LPA was informed by (1) staff that the new facility owner is S2. LPA called the licensee and S2 who informed S2 is managing the facility as the new administrator, however the licensee stated they are still involved in over seeing the facility. The licensee and S2 both confirmed that S2 is now leasing the property and that S2 will be applying for a change in ownership application. A copy of the current lease agreement was reviewed and revealed S2 is the leasing the property. The licensee revealed they did not send a notification of change in ownership to the department and entrusted this task to S2. Therefore, the facility is being cited for lack of reporting the intent to change ownership of the facility.

*LPA was off site from 12:20pm to 1:20pm in order to prepare today's report.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/08/2025 03:52 PM - It Cannot Be Edited


Created By: Janira Arreola On 07/08/2025 at 02:34 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: 07/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2025
Section Cited
CCR
87355(e)(3)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance...This requirement was not met as evidenced by:
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The licensee agreed to associate the staff to the facility and submit proof by the POC due date.
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Based on interview, records review and observation the licensee did not ensure S2 and S3 were associated to the facility prior to working at the facility. This poses an immediate health safety or personal rights risk to residents in care.
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Type A
07/09/2025
Section Cited
CCR8702(a)(2)

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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the...fire department...Prior to accepting or retaining any of the following types of persons...(2) Bedridden persons This requirement was not met as evidenced by:
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The licensee agreed to follow proper eviction procedures to issue the bedridden resident an eviction notice by the POC due date.
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Based on interview, observation and record review the facility has (1) bedridden resident in care and does not have proof of bedridden clearance. This poses an immediate health saftey or personal rights risk to residents 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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/08/2025 03:52 PM - It Cannot Be Edited


Created By: Janira Arreola On 07/08/2025 at 02:47 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: 07/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2025
Section Cited
CCR
87211(a)(1)(A)

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87211 Reporting Requirements (a) Each licensee shall furnish...such reports...including...(1)A written report...submitted to the licensing agency... within seven days of the occurrence of...(A)Death of any resident from any cause...This requirement was not met as evidenced by:
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The licensee agree to submit an incident report for the resident by the POC due date. The licensee also agree to obatin outside resource training on incident reporting and submit proof of training by the POC due date.
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Based on interview observation and record review the licensee did not report a resident death in a timely manner. This poses an immediate health saftey or personal rights risk to residents in care.
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Type A
07/09/2025
Section Cited
CCR87109(b)(1-2)

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87109 Transferability of License (b)...the property and business shall not be transferred until the buyer qualifies for a license or provisional license...(1)The seller shall notify, in writing, a prospective buyer of the necessity to obtain a license...if the buyer’s intent is to continue operating the facility...The seller shall send a copy of this written notice to the licensing agency.(2)The prospective buyer shall submit an application for a license...within five days of the acceptance of the offer..
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The licensee agreed to provide S2 with a written notice of the intent to change ownership and the need to apply for a license. This is due by the POC due date.
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This requirement was not met as evidenced by: Based on interview and record review the property was transferred to S2 and a notification of change in ownership was not provided to the department. This poses an immediate health safety or personal rights risk to residents in care.
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The licensee agreed to ensure S2 submits an application for a new license within (5) days as specified in this chapter and send proof to the LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2025


LIC809 (FAS) - (06/04)
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