336424393-1-12-2024-56-AS-PGUO-CZEQUZ-20240112112934

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336424393
Report Date: 01/12/2024
Date Signed: 01/12/2024 11:29:45 AM

Document Has Been Signed on 01/12/2024 11:29 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MIKE'S ANGELS LLC		FACILITY NUMBER:	336424393
ADMINISTRATOR:	MARTINEZ, LORENA		FACILITY TYPE:	740
ADDRESS:	318 SANDALWOOD DR		TELEPHONE:	(909) 795-0163
CITY:	CALIMESA	STATE: CA	ZIP CODE:	92320
CAPACITY:	6	CENSUS: 5	DATE:	01/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Lorena Martinez		TIME COMPLETED:	11:30 AM

NARRATIVE

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Licensing Program Analyst (LPA) Paola Guerrero 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 Five (5) 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 (5). LPA was accompanied by Facility Administrator,to conduct 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. 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 observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be 109 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 is 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: 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.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

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 01/12/2024 11:29 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MIKE'S ANGELS LLC	FACILITY NUMBER: 336424393
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(3)

1569.618 (3) Ensure that at least one staff member who has cardiopulmonary resucitation (CPR) training and first aid training is on duty and on the premises at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review the licensee did not comply with the section cited above in 5 out of 5 staff members did not have valid or updated First aid/CPR certification record on file. Which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2024
	Plan of Correction
1 2 3 4	Facility Administrator understands the importance of having staff trained on CPR and First Aid. Administrator has agreed to provide training and have all staff CPR and First Aid certified. Administrator will email proof of completed training to LPA Guerrero on POC date of 1/31/2024

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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MIKE'S ANGELS LLC	FACILITY NUMBER: 336424393
	VISIT DATE: 01/12/2024

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Record Review: LPA reviewed Five (5) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. During staff file review LPA did not observe current First aid/CPR certification. This poses a potential health & safety risk to residents in care. The administrator acknowledged this and stated training will be completed. Medications were audited at random and appeared to be dispensed appropriately by staff members.

Based on observations made during today’s inspection, the following deficiency is being cited per Title 22, "Staffing" 1569.618 (3) Division 6, of the California Code of Regulations. LPA reviewed this report with and a copy was provided to the facility representative along with appeal rights. See LIC 809, LIC 809D.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Lorena Martinez.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

LIC809 (FAS) - (06/04)

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