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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880544
Report Date: 12/04/2024
Date Signed: 12/04/2024 04:33:59 PM

Document Has Been Signed on 12/04/2024 04:33 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:
12/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:44 PM
MET WITH:Licensee, Angela ZhangTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility for an unrelated matter. The following report documents deficiencies observed during the visit. LPA met with Licensee, Angela Zhang who was informed of the purpose of the visit.

LPA conducted a walk through of the facility, (1) staff and (3) resident interviews which revealed the facility restrooms are not working properly and are in need of repair. LPA observed the common restroom on the hallway of the home, does not have hot water in the shower due to the faucet not moving to the hot setting. The staff stated the residents and staff use the private restroom to shower as the common restroom. LPA also checked the water in the private restroom in the master bedroom and observed that the water was coming out of the sink due a crack in it which spilled all over the bathroom floor. Deficiency was cited and plan of correction was created for licensee to fix the sink and shower.

LPA checked the facility hot water in the sinks and found the water was over 120F at 122F in the private restroom and 125F in the common restroom sinks. Deficiency was cited and a plan of correction was created with the licensee.

An exit interview was conducted where this report along with deficiencies and appeal rights were reviewed and provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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Document Has Been Signed on 12/04/2024 04:33 PM - It Cannot Be Edited


Created By: Janira Arreola On 12/04/2024 at 04:14 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: 12/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2024
Section Cited
CCR
87468.2(a)(1)

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(a) ...shall have...the following personal rights: (1)...reasonable level of personal privacy in accommodations…
This requirement was not met as evidenced by:
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The licensee agreed to fix the common shower of the facility and inform the LPA when the repairs are completed. The licensee agreed to send proof of repiar by the POC due date.
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Based on interview and observation, the private shower in the master bathroom is being used by all staff and residents. This poses a potential personal rights, health or saftey risk to residents incare.
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Type B
12/13/2024
Section Cited
CCR87303(e)(2)

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(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 more than 120 degree F (49 degree C). This requirment was not met as evidenced by:
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The licensee agreed to adjust the water temperature to the required range. The licensee agreed to send proof of the required temperature b y the POC due date.
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Based on observation the water temperature in the facility restrooms read 122F and 125F. This poses a potential 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.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
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