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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426543
Report Date: 08/14/2023
Date Signed: 08/14/2023 12:54:35 PM

Document Has Been Signed on 08/14/2023 12:54 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ANGELVIEW CARE HOMES, INC. @ DARWINFACILITY NUMBER:
336426543
ADMINISTRATOR:MARIE KRIS BOCOFACILITY TYPE:
735
ADDRESS:13852 DARWIN DR.TELEPHONE:
(951) 780-4990
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 6DATE:
08/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver Nancy TorioTIME COMPLETED:
01:15 PM
NARRATIVE
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On 8/14/2023, at 9:30 a.m., Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Ronald Ramon Torio who was informed of the purpose of visit. Administrator May Embalsado arrived later during the visit and provided LPA with client and staff files previously removed from the facility.

During the visit, there was six (6) clients and three (3) staff present. The facility is approved to care for six (6) non-ambulatory clients, of which two (2) may be bedridden. LPA toured the facility’s interior and exterior. During the visit, LPA observed the following:
Bedrooms: Client bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Detectors/Fire Extinguisher: Carbon monoxide and smoke detectors were tested and functioning properly. Fire extinguisher is charged and mounted on kitchen wall.

Kitchen: LPA observed the facility did not have a 2-day food supply of perishable food items. LPA observed an unsecured knife and pair of scissors on kitchen countertop. LPA observed menu posted on the refrigerator based on the USDA Basic Food Group Plan – Daily Food Guide; however, LPA observations along with Staff and Administrator interviews revealed that the facility is not following the menu posted and the facility provides menu substitutions for Client #3 without consulting a facility dietitian, registered dietitian, physician or medical provider for Client #3's recommended 1500 calorie ADA diet. Three deficiencies were cited regarding the above-mentioned.

Continued on LIC809-C..

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2023
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
Document Has Been Signed on 08/14/2023 12:54 PM - It Cannot Be Edited


Created By: Janette Romero On 08/14/2023 at 11:31 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGELVIEW CARE HOMES, INC. @ DARWIN
FACILITY NUMBER: 336426543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in due to LPA observing unsecured cleaning solutions and Clorox wipes on kitchen countertop, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Licensee agreed to provide staff training regarding securing disinfectants and cleaning solutions and making them inaccessible to clients in care. Proof of correction to be submitted to CCLD by close of business on POC due date.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above due to LPA observing the facility did not have a 2-day supply of perishable food items on the premises, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Licensee agreed to purchase a 2-day supply of perishable food items and provide proof of correction to CCLD by close of business on 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:Joel Esquivel
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/14/2023 12:54 PM - It Cannot Be Edited


Created By: Janette Romero On 08/14/2023 at 11:31 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGELVIEW CARE HOMES, INC. @ DARWIN
FACILITY NUMBER: 336426543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above due to LPA observing the key to the medication cart is left inside the medication cart lock, leaving access to clients in care, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Licensee agreed to provide staff training regarding securing centrally stored medications. Proof of correction to be submitted to CCLD by close of business on POC due date.
Type B
Section Cited
CCR
80092.8(a)(6)
(a) A licensee of an adult CCF may accept or retain a client who has diabetes if all of the following conditions are met:
(6) The licensee provides a modified diet as prescribed by a client's physician, as specified in Section 80076(a)(6). Any substitutions shall be made by the facility dietitian or in consultation with a registered dietician or the client's physician or medical provider.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by providing menu substitutions for Client #3 without consulting a facility dietitian/registered dietitian, Client #3's physician or medical provider, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Licensee agreed to consult a facility dietitian, registered dietitian, Client #3's physician or medical provider regarding appropriate menu substitutions for Client #3's recommended 1500 calorie ADA diet and provide documentation to CCLD by close of business on 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:Joel Esquivel
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


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Document Has Been Signed on 08/14/2023 12:54 PM - It Cannot Be Edited


Created By: Janette Romero On 08/14/2023 at 11:42 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGELVIEW CARE HOMES, INC. @ DARWIN
FACILITY NUMBER: 336426543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(d)
80070 Client Records

(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above due to Administrator removing four (4) client records from the premises, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Licensee agreed to implement a policy instructing administrative staff to not remove any client files from the premises. Proof of correction to be submitted to CCLD by close of business on POC due date.
Type B
Section Cited
CCR
80066(c)
80066 Personnel Records
(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above due to Administrator removing three (3) personnel files from the premises, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Licensee agreed to implement a policy instructing administrative staff to not remove any personnel files from the premises. Proof of correction to be submitted to CCLD by close of business on 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:Joel Esquivel
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANGELVIEW CARE HOMES, INC. @ DARWIN
FACILITY NUMBER: 336426543
VISIT DATE: 08/14/2023
NARRATIVE
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Centrally Stored Medications: LPA observed a first aid kit with required components. Medications are stored in medication cart in the dining room. LPA observed medication cart keys are left inside medication cart lock and are accessible to clients in care. Deficiency cited. LPA reviewed physical medications for Client #1 and Client #2 as well as the Medication Administration Record used to log administration of clients’ medications. No discrepancies discovered.

Bathrooms: Bathrooms have a working toilet, wash basin, and were equipped with a grab bar in the shower. The facility has clean towels, blankets, and linen, available in different colors for the clients in care.

Laundry/Garage: LPA toured the laundry room and garage to be clean. Washing machine and dryer are all in good repair. Emergency food supplies, water, additional linen, PPE, and incontinent supplies are stored in the garage.

Records: Staff present have a criminal record clearance on file and are associated to the facility. Staff training is up to date. During LPA's arrival at the facility, LPA requested random staff and client files from Caregiver Torio.

Caregiver Torio informed LPA that the facility only had two client (2) files on the premises and the remaining four (4) client files, along with staff files were removed from the premises by Administrator Embalsado as the facility prepared for an audit from Inland Regional Center. Deficiency cited.

Yard/Outside Area: A wood wall secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

LPA observed a total of six (6) deficiencies faulting the facility. An exit interview was conducted, and a copy of this report was discussed and provided to Administrator Embalsado along with LIC809-D pages and Appeals Rights.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC809 (FAS) - (06/04)
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