336403894-2-16-2024-18-AS-CCON-D2HUKH-20240216143911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336403894
Report Date: 02/16/2024
Date Signed: 02/16/2024 02:39:43 PM

Document Has Been Signed on 02/16/2024 02:39 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:	ANGELVIEW CARE HOMES, INC. (AT SHADOWBROOK)		FACILITY NUMBER:	336403894
ADMINISTRATOR:	FAITH AUMENTADO		FACILITY TYPE:	735
ADDRESS:	12640 SHADOWBROOK STREET		TELEPHONE:	(951) 485-3490
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY:	4	CENSUS: 4	DATE:	02/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	May Boco - Administrator		TIME COMPLETED:	02:45 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	Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator May Boco and informed her of the purpose of today's inspection. Below is a summary of what was observed: Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include: soap and paper towels at hand washing stations, hand washing guides posted, and monitoring the residents and staff for symptoms of infectious diseases. Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin observed the facility to be a comfortable temperature of 75 degrees and that the hot water in the bathroom faucets measured at 105.6 degrees. LPA Colvin did not observe any obstructions to emergency exits or hallways/walkways. LPA Colvin observed staff testing the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives and dangerous chemicals were locked in a cabinet in the kitchen, away from residents' reach. LPA Colvin observed a broken down van in the facility's driveway with a flat tire. LPA Colvin previously observed this vehicle during an inspection on 4/13/22, and had been informed that it was being donated and would be removed from the property. LPA Colvin issued a Technical Advisory note at the time in show of good faith, but since the vehicle is still present, LPA Colvin will be issuing a deficiency. Deficiency cited. Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 4 non-ambulatory residents.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

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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Document Has Been Signed on 02/16/2024 02:39 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: ANGELVIEW CARE HOMES, INC. (AT SHADOWBROOK)	FACILITY NUMBER: 336403894
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: ANGELVIEW CARE HOMES, INC. (AT SHADOWBROOK)	FACILITY NUMBER: 336403894
	VISIT DATE: 02/16/2024

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Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that there is a certified Administrator present. LPA Colvin confirmed staff have criminal record clearance and have training to perform their required duties. Staff present have current CPR/First Aid Certification and have other relevant training listed in their files.

Resident Records: LPA Colvin reviewed the files for all 4 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin observed that two residents (R1 & R2) did not have a recent Needs and Services Plan or Individual Program Plan (IPP) in their files. Administrator May Boco was able to show LPA Colvin an electronic copy of the records on her phone. LPA Colvin recommended to Administrator May Boco that she insure the records are printed and maintained in the residents files in the future. LPA Colvin will be issuing a Technical Violation instead of a deficiency as Administrator May Boco was able to make the records accessible to LPA Colvin during today's inspection. LPA Colvin interviewed all 4 residents at the facility and additionally reviewed medications and did not observe any concerns during today's inspection.

Food Services: LPA Colvin observed the facility to have the required amount of perishable and non-perishable food. LPA Colvin observed the kitchen and dining area to be maintained in a clean and healthful manner. Sufficient dishware and silverware was present for residents use.

Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet in the kitchen and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions, though they do retain residents with Restricted Health Conditions and have the required Care Plans and training on file.

Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file and conducts regular Emergency Disaster drills.

An exit interview was conducted with Administrator May Boco and a copy of this report, LIC9102, LIC809D, and appeal rights were provided.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC809 (FAS) - (06/04)

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