331881293-4-14-2022-56-AS-RLAA-CDGP5Q-20220414110108

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881293
Report Date: 04/14/2022
Date Signed: 04/14/2022 11:01:21 AM

Document Has Been Signed on 04/14/2022 11:01 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	ANGELES HOME CARE		FACILITY NUMBER:	331881293
ADMINISTRATOR:	MATAMOROS, MICHELLE		FACILITY TYPE:	740
ADDRESS:	32650 WESLEY STREET		TELEPHONE:	(951) 226-8259
CITY:	WILDOMAR	STATE: CA	ZIP CODE:	92595
CAPACITY:	6	CENSUS: 5	DATE:	04/14/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Michelle Matamoros, Administrator		TIME COMPLETED:	11:15 AM

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Licensing Program Analyst (LPA) Rohit Lama conducted an announced visit to the pending facility for a pre-licensing inspection. LPA met with Michelle Matamoros, Administrator.

This facility was previously licensed as Angeles Home Care (same name) and Facility Number: 336426431, and is undergoing a change of ownership. The pending application is for a capacity of six (6) residents: six (6) non-ambulatory OR three (3) Non-ambulatory and three (3) bed-ridden in a Residential Care Facility for the Elderly (RCFE).

Fire clearance was granted by the City of Lake Elsinore Office of the Fire Marshall for two (2) non-ambulatory and four (4) bed-ridden. There are charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. Emergency disaster plans, personal rights, and the Community Care Licensing poster were posted in a prominent area. The facility was equipped with a complete first aid kit and manual as well as emergency supplies.

LPA toured the facility inside and out. The following was observed, reviewed, and inspected:

The facility has 6 bedrooms, in which 5 bedrooms are designated for residents, and 1 bedrooms are designated for staff, 3 bathrooms, living room, kitchen, dining area, backyard, and attached garage.

The physical plant, in general, was in good repair. The buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. LPA observed an in-ground pool in the backyard, the perimeter of pool is gated and locked. LPAs inspected the backyard. There was a shaded area with seating. There was no obstruction on the side yard exits. The gates remained unlocked.

LPA was informed that no firearms or ammunition will be kept at facility. The Administrator has a current Administrator's Certificate with an expiration date of: 08/02/2023.

(continuation on LIC809C)

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit Lama	TELEPHONE: 951-217-9826
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: ANGELES HOME CARE	FACILITY NUMBER: 331881293
	VISIT DATE: 04/14/2022

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LPA inspected resident bedrooms. Resident bedrooms have the required bedding and furniture. All bedrooms included clean mattresses, closet space, night stands, dressers, and sufficient lighting. LPAs inspected resident bathrooms. The bathrooms were operating in safe and sanitary conditions. LPAs measured the hot water temperature, which measured within regulation at 110 degrees F. LPA also observed additional linen and hygiene items for the residents. LPA toured the kitchen. The facility had a 2-day supply of perishable food items and 7-day supply of non-perishable food items. The food was labeled with expiration dates and stored in a safe and healthful manner. The facility had a menu available for review. Dishes, glasses, and utensils were in good condition.

There was a locked and centralized storage area for medications. Cleaning supplies, toxins, and sharps were kept locked away and inaccessible to residents. Additionally, LPA observed facility to have required single entry point for COVID screening, upon entering facility. LPA observed required COVID signages throughout the facility, Visitation Vaccination Requirement and soap and disposable towels in bathrooms for washing hands.

The facility had a designated area for resident and staff files, which was locked. The facility had working telephones for residents’ use. There was adequate seating in the common areas. LPAs observed activities for the residents such as books and games.

At this time facility has shown to have met pre-licensing requirements.

The facility was evaluated in accordance with Title 22, Division 6, Chapters 1 to ensure the health and safety of residents in care and meets regulation guidelines at this time.

No corrections are needed.

An exit interview was conducted, and a copy of this report (LIC 809) was reviewed with and provided to the Administrator.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit Lama	TELEPHONE: 951-217-9826
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

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