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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880544
Report Date: 03/05/2026
Date Signed: 03/05/2026 12:13:57 PM

Document Has Been Signed on 03/05/2026 12:13 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:
03/05/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Manager, Carina RipotolaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On March 5, 2026, Licensing Program Analyst (LPA), Jarred Torres, arrived at the facility unannounced to conduct an annual inspection and met with Manager, Carina Ripotola. A facility file review was conducted at the regional office and additional records were requested and reviewed at the facility. Their files were stored and maintained in a secure area. The facility is licensed for six adults and was operating at a capacity of five adults.

LPA Torres toured the facility along with Carina and made observations pertaining to the annual inspection. The LPA inspected the facility inside and outside. There were no obstructions on the indoor and outdoor passageways at the time of this visit. Additionally, there were no bodies of water on the premises. The single-story home was located at 13247 Sunbird Drive, Moreno Valley, CA 92553.

During the tour of the premises, the LPA observed the facility phone to be operable. The facility's phone number is 951-208-1306. The LPA observed the residents' bedrooms which were equipped with the required furniture as stated in Tittle 22 of the California Code of Regulations (CCR). The facility's appliances were observed to be operational at the time of this visit. The facility is equipped with operational smoke detectors and a carbon monoxide detector. The fire extinguisher was in good condition and was serviced on 10/21/25. Required postings regarding safety, personal rights, and emergency exits were posted in the home. The cleaning supplies and sharp items were kept locked and inaccessible to residents in care.

Continued on LIC 809-C...
NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Jarred Torres
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2026
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: 03/05/2026
NARRATIVE
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The furniture in the facility was in good condition. The facility's cooling and heating system is operational and the air temperature was at 70 degrees Fahrenheit(F) and the hot water was measured at 112 degrees F.

The LPA observed the medications to be locked and inaccessible to clients in care. The medication supply was sufficient for the five clients in care. There were no discrepancies with the centrally stored medications and Medication Administration Records.

In the kitchen, the food supply of non-perishable and perishable foods consisted of, but not limited to, bread, frozen meats, vegetables, juice, water, and fruits. The facility goes grocery shopping one to two times per week and maintains an appropriate food supply for the five clients in care.

Adequate staff was present for the supervision of the residents in care. The facility has a designated area for storing activity supplies and activities are conducted in the living room. Floor plans, telephone numbers and personal rights were displayed in the facility. Administrator, Dulce Redford, had a valid administrator's certificate on file, which expires on 10/3/2027.

Client files and staff files were reviewed. Three staff files were reviewed and one did not contain a tuberculosis test. This was discussed with Carina and a plan of correction was developed. During the LPA's review of client files, the LPA observed that three of three reviewed files did not contain a signed copy of the clients' personal rights. This was discussed with Carina and a plan of correction was developed.

The LPA reviewed the emergency disaster plan and fire clearance. The emergency disaster plan meets the department's standards, and the next emergency drill is scheduled for March 25, 2026.

The LPA inspected the bathrooms and observed the hand washing stations to have the required non-medicated soaps and single-use hand towels. Furthermore, the bathrooms are free of dust and debris. Additionally, the facility has an approved infection control plan in their files.

Before leaving the facility, the LPA provided the manager with various LIC forms to help keep their staff and client files organized. An exit interview was conducted and this report was reviewed with the manager, Carina Ripotola. A copy of this report, deficiencies, and appeal rights were provided to the manager, whose signature confirms receipt.
NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Jarred Torres
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/05/2026 12:13 PM - It Cannot Be Edited


Created By: Jarred Torres On 03/05/2026 at 11:48 AM
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: 03/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on three reviewed staff files, the licensee did not comply with the section cited above where one of those files did not have a chest x-ray nor intradermal test completed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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Carina Ripotola will provide a picture or scan of the medical form that shows the staff file is current with the required chest x-ray or intradermal test.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jazmond D Harris
NAME OF LICENSING PROGRAM MANAGER:
Jarred Torres
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/05/2026 12:13 PM - It Cannot Be Edited


Created By: Jarred Torres On 03/05/2026 at 11:48 AM
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: 03/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)(1)(A)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in three of three record reviews, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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Manager, Carina Ripotola, will provide a scan of the signed personal rights forms via e-mail to the LPA's e-mail address by 3/27/26.
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.
Jazmond D Harris
NAME OF LICENSING PROGRAM MANAGER:
Jarred Torres
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2026


LIC809 (FAS) - (06/04)
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