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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403508
Report Date: 05/23/2023
Date Signed: 05/25/2023 08:49:50 AM


Document Has Been Signed on 05/25/2023 08:49 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
RIVERSIDE, CA 92507



FACILITY NAME:ANGEL HOME CAREFACILITY NUMBER:
336403508
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:31555 AVENIDA DEL PADRETELEPHONE:
(760) 202-2312
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:6CENSUS: 5DATE:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Joshua Rocha, AdministratorTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card.

Resident record review began. Two (2) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort; additional lightning for shower area and toilet needs repair. Water temperature measured 105.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location.



Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized.


(Continued on next page)
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
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 5


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
RIVERSIDE, CA 92507
FACILITY NAME: ANGEL HOME CARE
FACILITY NUMBER: 336403508
VISIT DATE: 05/23/2023
NARRATIVE
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LPA began review of employee records. Two (2) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 12/15/2022. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 12/2014 according to documentation observed.

LPA allocated time to prepare this report for delivery.

Based on the information received during this visit today, there are six (6) deficiencies and one (1) Technical Assistance that are being cited per Title 22, Division 6 of The California Code of Regulations.

This report, LIC809D, Appeal Rights was reviewed with and a copy will be emailed and a request for confirmation will be requested from the facility.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/25/2023 08:49 AM - 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ANGEL HOME CARE
FACILITY NUMBER: 336403508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(d)
Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgdo's observation, the licensee did not comply with the section cited above in out of which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed insufficient light for bathroom #1 shower area.
POC Due Date: 06/13/2023
Plan of Correction
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2
3
4
Licensee will obtain light for shower area and send a photograph via email to LPA by POC due date.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed toilet in bathroom #2 does not flush.
POC Due Date: 06/13/2023
Plan of Correction
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Licensee will have toilet fix/repair and send a self-certifying statement to LPA via email by 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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5


Document Has Been Signed on 05/25/2023 08:49 AM - 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ANGEL HOME CARE
FACILITY NUMBER: 336403508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(6)(A)
Personnel Records
(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA did not observed education verification in file for Administrator.
POC Due Date: 06/13/2023
Plan of Correction
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Licensee will obtain copy of education and place in staff file and submit via email a copy to LPA by POC due date.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed R1 and R2's medication punched out of bubbe pack and in a different containers for PM meds and next days dispensing
POC Due Date: 06/13/2023
Plan of Correction
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Licensee will conduct In-service training will all staff on the proper dispensing of medications for residents and send a copy of the training via email to LPA by 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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 05/25/2023 08:49 AM - 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ANGEL HOME CARE
FACILITY NUMBER: 336403508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed emergency food not discernible from pantry food and additional emergency water.
POC Due Date: 06/13/2023
Plan of Correction
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Licensee will discern emergency food and obtain addtional water and relocate in an accessible area and send a photograph via email to LPA by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed last drill conducted on December 2014.
POC Due Date: 06/13/2023
Plan of Correction
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Licensee will conduct quarterly drills and document and will submit plan of quarterly drills via email to LPA by 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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5