331881472-10-10-2023-18-AS-JROO-CWGQHT-20231010121139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881472
Report Date: 10/10/2023
Date Signed: 10/10/2023 12:11:44 PM

Document Has Been Signed on 10/10/2023 12:11 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:	ANGEL HOMECARE		FACILITY NUMBER:	331881472
ADMINISTRATOR:	ROCHA, BERNARDA		FACILITY TYPE:	740
ADDRESS:	31555 AVENIDA DEL PADRE		TELEPHONE:	(760) 202-2312
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY:	6	CENSUS: 5	DATE:	10/10/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Administrator, Bernarda Rocha		TIME COMPLETED:	12:30 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	On Tuesday, 10/10/2023, Licensing Program Analyst (LPA) Janette Romero conducted an announced visit to conduct a pre-licensing inspection. The facility is undergoing a change of ownership. LPA was informed by Administrator Bernarda Rocha that Applicant Joshua Rocha was unavailable to meet with LPA at the time of LPA's visit. Fire clearance has been granted for (6) non-ambulatory elderly residents. Applicant Rocha's administrator certificate expires on 1/23/2025. LPA conducted of a tour of the facility’s interior and exterior. The facility is made up of five (5) resident bedrooms and four (4) resident bathrooms along with a kitchen, living/family room, and garage. LPA did not observe bodies of water on the premises. The physical plant is in good repair. Indoor and outdoor passageways are free of obstructions. The facility has an outside shaded seating area available for the residents. LPA observed a charged fire extinguisher, operating smoke alarms, carbon monoxide detectors, and a working land line. LPA observed a locked storage area for cleaning solutions, centrally stored medications, and knives/sharp instruments. Resident and staff files are secured in a file cabinet stored near the kitchen. Continued on LIC809-C..

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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: ANGEL HOMECARE	FACILITY NUMBER: 331881472
	VISIT DATE: 10/10/2023

NARRATIVE

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Continued from LIC809.

LPA toured the bedrooms. Resident bedrooms had the required bedding, furniture, and functional lighting. Additional linen and towels are available in the hallway cabinet. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a 2-day supply of perishable food and 7-day supply of nonperishable food items. LPA also observed emergency food and water stored in the kitchen.

LPA toured the resident bathrooms. Resident bathrooms are equipped with grab bars and non-skid mats in the shower. The hot water temperature in resident bathrooms measured at 106-degrees Fahrenheit.

Emergency disaster plans, personal rights, and complaint procedures were posted in living/family room wall. LPA observed two complete first aid kits. Living/family room has a working television and adequate seating in common areas.

During today's visit, LPA did not observe any issues or concerns. Administrator Rocha is scheduled to complete the Comp III on Thursday, 10/12/2023, at 9:00 a.m., at the Riverside Regional Office. Final approval of licensure will be granted by the Centralized Application Bureau analyst.

An exit interview was conducted where a copy of this report was discussed and provided to Administrator Rocha.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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