331880544-12-4-2024-18-AS-JARA-DBN2P7-20241204163353

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 HOME		FACILITY NUMBER:	331880544
ADMINISTRATOR/ DIRECTOR:	ANGELA ZHANG		FACILITY TYPE:	740
ADDRESS:	13247 SUNBIRD DR		TELEPHONE:	(951) 653-0652
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/04/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:44 PM
MET WITH:	Licensee, Angela Zhang		TIME VISIT/ INSPECTION COMPLETED:	04:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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.

Tricia Danielson	TELEPHONE: (951) 202-5067
Janira Arreola	TELEPHONE: 951-233-6759
	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

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: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(a) ...shall have...the following personal rights: (1)...reasonable level of personal privacy in accommodations… This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 12/27/2024
	Plan of Correction
1 2 3 4	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.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Tricia Danielson	TELEPHONE: (951) 202-5067
Janira Arreola	TELEPHONE: 951-233-6759
	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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