331880992-10-19-2023-18-AS-JARA-CWRSNA-20231019140114

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880992
Report Date: 10/19/2023
Date Signed: 10/19/2023 02:01:24 PM

Document Has Been Signed on 10/19/2023 02:01 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:	ANGELICUM RCFE		FACILITY NUMBER:	331880992
ADMINISTRATOR:	REYES, VIVIAN E		FACILITY TYPE:	740
ADDRESS:	112 ROMANZA LN		TELEPHONE:	(224) 814-7022
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92211
CAPACITY:	6	CENSUS: 6	DATE:	10/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:28 AM
MET WITH:	Administrator, Vivian Reyes		TIME COMPLETED:	11:36 AM

NARRATIVE

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On 10/19/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Vivian Reyes, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (6) residents present.

The facility is a one story home with (4) bedrooms and (2) bathrooms. No pools or firearms are present. The residents served are elderly ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following:

Infection Control: The LPA observed hand washing stations with hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan to train and follow infection control guidelines.

Physical Plant: Physical plant was observed to be clean and in good repair. The indoor and outdoor areas were observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide was operational, and the hot water temperature was recorded at 105.4F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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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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: ANGELICUM RCFE	FACILITY NUMBER: 331880992
	VISIT DATE: 10/19/2023

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Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. The listed administrator has a current administrator's certificate. Resident files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: The following issues will be cited. Based on interview with Administrator and records review, this PRN was not authorized by Resident 1 (R1)'s primary care physician. The facility currently has a waiver for three (3) hospice residents, however based on interview with administrator the facility currently has (5) residents on hospice. The administrator stated they sent a waiver increase letter that was sent to the department but was unable to provide a copy during the visit. According to California Code of Regulations Title 22, a licensee shall not retain a hospice resident without first securing a hospice waiver from the department. Plans of correction were created with the administrator for these deficiencies.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The last fire drill was conducted 7/18/23, the facility is due for another fire drill this month. LPA will document Technical advisory note and administrator agreed to hold fire drill by 10/31/2023. LPA observed emergency exits and emergency supplies.

The licensee currently has not paid their annual fees. The administrator was able to show proof of sending a payment 8/23/2023. LPA provided balance information and how the payment can be made or disputed with the department.

An exit interview was conducted where a copy of this report, along with LIC809-D page, and appeal rights were provided to Administrator, Vivian Reyes.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/19/2023 02:01 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: ANGELICUM RCFE	FACILITY NUMBER: 331880992
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87632(a)

87632 Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department.... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based oninterview and record review, the licensee did not comply with the section cited above with (5) hospice residents when approved waiver on file is for (3). No documentation of an increase was found in file review and Administrator was unable to provide a copy of an increase letter. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/02/2023
	Plan of Correction
1 2 3 4	The administrator agreed to send an increase letter to the department by the POC due date. The administrator was provided with guidelines for the letter.

Type B

Section Cited

CCR

87465(e)

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication.... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with PRN medication which was being given to R1 without a doctor's approval. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/02/2023
	Plan of Correction
1 2 3 4	The administrator agreed to have a written doctor's note with required elements in the section cited for R1's PRN medication. This is due to the LPA by the POC due date.

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: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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