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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880544
Report Date: 06/30/2023
Date Signed: 06/30/2023 11:57:38 AM


Document Has Been Signed on 06/30/2023 11:57 AM - 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:ANGELA ZHANGFACILITY TYPE:
740
ADDRESS:13247 SUNBIRD DRTELEPHONE:
(951) 653-0652
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:6CENSUS: 6DATE:
06/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Caregiver Feng ZhuTIME COMPLETED:
09:34 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to the facility to conduct a complaint investigation (18-AS-20230623101311).

While LPA met with Licensee Yingzi Zhang, LPA initially met with Caregiver Feng Zhu. LPA explained the purpose of the visit, and was granted entry. LPA toured the facility. When checking the employee roster, LPA found that Zhu was not located on the roster. Additionally, LPA conducted a record review, and found that Zhu was not found to have a current approved background through the Department of Justice. Zhu indicated that they have been providing care to resident for approximately 1 month.

When questioned, Zhu indicated that they provide incontinence care to residents, and cook, and clean the facility. Thus, the facility was cited per Title 22. LPA conducted a tour of the facility and found no other deficiencies. At the conclusion of the visit, LPA observed S1 leave the facility.

An exit interview was conducted where a copy of this report was discussed with and provided along with a copy of the LIC421BG, LIC8099D, and Appeal Rights.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
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 06/30/2023 11:57 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2023
Section Cited
CCR
87355(e)(1)

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Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or
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Licensee agrees to immediately remove S1 from the facility. Licensee will further conduct in-service training on the cited reguation and provide proof of such by POC
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Based on record review, LPA found that S1 did not have an approved clearance to provide care to residents. This is an immediate 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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
LIC809 (FAS) - (06/04)
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