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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880544
Report Date: 07/28/2023
Date Signed: 07/28/2023 02:21:37 PM


Document Has Been Signed on 07/28/2023 02:21 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:ANGELA ZHANGFACILITY TYPE:
740
ADDRESS:13247 SUNBIRD DRTELEPHONE:
(951) 653-0652
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY:6CENSUS: 7DATE:
07/28/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Angela Zhang, Licensee/AdministratorTIME COMPLETED:
01:15 PM
NARRATIVE
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An Informal Conference was conducted today in order to discuss issues of concern with the facility progress and operation. Persons present at today’s meeting were: Licensing Program Manager (LPM) Joel Esquivel, Licensing Program Analyst (LPA) Jesse Gardner, and Licensee/Administrator Angela Zhang.

Below are the topics that were addressed during the Office Conference:
  • Lack of Records
  • Uncleared Staff
  • Reporting Requirements
  • Not reporting resident change of condition to POA's/relevant parties
  • Resident right's to their own medical care
  • Communication with resident emergency contacts
  • Current serious complaints

During this meeting the Regional Office made an offer to refer the licensee for Technical Assistance Program (TSP). The licensee agreed to participate in the TSP program.

During the office conference, and interview with Licensee Angela Zhang, it was discovered that Licensee has 7 residents in care. Licensee Zhang is only permitted a capacity of 6 at their facility. This is a violation of Title 22. Facility cited.

An exit interview was completed where a copy of this report was provided along with copies of the LIC809-D, and Appeal Rights.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
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 07/28/2023 02:21 PM - 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: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2023
Section Cited
CCR
87158(a)

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Capacity:
A license shall be issued for a specific capacity which shall be the maximum number of residents which can be provided care at any given time. This requirement was not being met as evidenced by:
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Licensee agrees to provide a plan to relocate a resident by POC date. The plan will include the new location of the resident and submit by POC date.
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Based on interview with Licensee, Licensee indicated that they are over capacity by one resident. This presents an immediate health and safety 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: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
LIC809 (FAS) - (06/04)
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