336424393-1-22-2025-56-AS-BALN-DD6TAB-20250122133318

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336424393
Report Date: 01/22/2025
Date Signed: 01/22/2025 01:33:24 PM

Document Has Been Signed on 01/22/2025 01:33 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	MIKE'S ANGELS LLC		FACILITY NUMBER:	336424393
ADMINISTRATOR/ DIRECTOR:	MARTINEZ, LORENA		FACILITY TYPE:	740
ADDRESS:	318 SANDALWOOD DR		TELEPHONE:	(909) 795-0163
CITY:	CALIMESA	STATE: CA	ZIP CODE:	92320
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	01/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:05 AM
MET WITH:	Arcelia Agulie- Support Staff		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

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Licensing Program Analyst (LPA)Bernadette Allen made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Administrator Lorena Martinez and was granted entry to the facility.

At the time of the visit there was two (2) staff present, and Four (4) residents present.

The facility is a Four (4) bedroom, Four (4), bathroom home, with a kitchen/dining area, living room, and attached garage. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (6) current census (4). LPA was accompanied by Arcelia Agulie- Support Staff who assisted with a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature 75 degrees F. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA measured and observed the water temperatures in the bathrooms to be 109- 111 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms.

Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside medication closet inaccessible to residents in care. Overall, the facility appears to be clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care.

Care & Supervision: The facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Karen Clemons	TELEPHONE: (951) 248-0349
Bernadette Allen	TELEPHONE: 951-897-2618
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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: MIKE'S ANGELS LLC	FACILITY NUMBER: 336424393
	VISIT DATE: 01/22/2025

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Record Review: LPA reviewed two (2) resident files for admission agreements, updated physician reports, and needs and services plans.

LPA also reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings.

Medications were audited at random and were missing signatures on 1/21/2025 as to when medications were given.

Based on the observations made during today’s visit, a Technical Advisory was cited for not documenting when the residents medications were given to residents 1,2,3, & 4 Regulation 87465(a)(6). The administrator Lorena Martinez has agreed to provide training on the cited regulation and provide a statement of understanding signed by all staff members by 1/28/2025.

An exit interview was conducted, and this report was discussed and provided to Lorena Martinez Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

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