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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881044
Report Date: 06/19/2023
Date Signed: 06/19/2023 04:52:36 PM

Document Has Been Signed on 06/19/2023 04:52 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ANGELVIEW CARE HOMES, INC. @ SAMANTHAFACILITY NUMBER:
331881044
ADMINISTRATOR:EMBALSADO, MAY BOCOFACILITY TYPE:
735
ADDRESS:23099 SAMANTHA PLACETELEPHONE:
(951) 780-4990
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 2DATE:
06/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Caregiver Loreta FiguracionTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janette Romero conducted an unannounced annual required visit to the facility at 3:15 p.m. LPA was greeted and granted entry by Caregiver Loreta Figuracion who was informed of the purpose of the visit. During the visit, there were two (2) clients, and two (2) staff present.

The facility is made up of a one-story home with two (2) client bedrooms, two (2) bathrooms, family room, dining area, kitchen, and an attached garage. LPA conducted a tour of the interior and exterior. LPA observed the following:

Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Client bathrooms have a working toilet, wash basins, and were equipped with a grab bar and non-slip mat in the shower. The facility has clean towels, blankets, and linen, available in different colors for each client. Cleaning solutions are secured in a locked cabinet in the bathroom.

Kitchen: LPA observed a sufficient supply of dishes, glasses, utensils, pots, and pans. Sharps and knives are secured in a locked kitchen cabinet. Sample menu is posted on refrigerator door. The stove is operational. Refrigerator and freezer were in working condition. LPA observed minimum required supply of perishable and non-perishable food available for the clients. A fire extinguisher was charged and mounted near the kitchen.

Laundry: Laundry area had an operating washer and dryer.

Centrally Stored Medications: LPA observed a first aid kit with required components. Client medications are secured in a cabinet near the kitchen.

Continued on LIC809-C..

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 06/19/2023 04:52 PM - It Cannot Be Edited


Created By: Janette Romero On 06/19/2023 at 04:29 PM
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: ANGELVIEW CARE HOMES, INC. @ SAMANTHA
FACILITY NUMBER: 331881044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(d)
80070 Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, client records were unavailable for review due to Administrator removing client records from the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
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Facility will ensure client records are returned to the facility and are readily available for review moving forward. Facilty will provide proof of correction to CCLD by close of business on 6/20/2023.
Type B
Section Cited
CCR
80066(c)
80066 Personnel Records

(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, personnel records were unavailable for review due to Administrator removing records from the facility, which which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
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Facility will ensure client records are returned to the facilty and provide proof of corrections to CCLD by close of business of 6/20/2023.
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 Esquivel
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023


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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANGELVIEW CARE HOMES, INC. @ SAMANTHA
FACILITY NUMBER: 331881044
VISIT DATE: 06/19/2023
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Living/Family room: The family room had a working television for the clients in care. Let-Us-No poster, emergency phone numbers, and facility sketch were posted in the hallway.

Yard/Outside Area: Shaded outside seating is available for the clients. A brick wall and gate secured the entire backyard. All outdoor pathways were free of obstructions. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

Administrator May Embalsado arrived during the visit. LPA was unable to review personnel and client records due to Administrator Embalsado removing personnel and client records from the facility since Thursday, 6/15/2023.

As a result the following deficiencies were cited in accordance with California Code of Regulations, Title 22, Division 6:

80070 Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.

An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Embalsado.

80066 Personnel Records

(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.

A copy of this report was discussed and provided to Administrator Embalsado along with an LIC809-D and Appeal Rights.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC809 (FAS) - (06/04)
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