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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426747
Report Date: 08/21/2024
Date Signed: 08/26/2024 06:16:41 PM


Document Has Been Signed on 08/26/2024 06:16 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:ANGELIC HANDS ASSISTED LIVINGFACILITY NUMBER:
336426747
ADMINISTRATOR:LUNA, SYNTHIA MARIEFACILITY TYPE:
740
ADDRESS:82397 STRADIVARI ROADTELEPHONE:
(760) 342-0248
CITY:INDIOSTATE: CAZIP CODE:
92203
CAPACITY:6CENSUS: 4DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Caregiver Tinisha SherleyTIME COMPLETED:
05:35 PM
NARRATIVE
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On 8/21/24 Licensing Program Analyst's (LPAs) Valerie Flores, Ferrer Sabarias, and Andrei Castillo conducted an unannounced one (1) year required visit. LPA's were granted entry by caregiver, Tinisha Sherley, who was informed of the purpose of visit. At the time of the visit there were one (1) staff, and four (4) residents present. Staff present was observed to have obtained proper fingerprint clearance and associated to the facility. LPA's observed the following during today's visit:

LPA's conducted a tour of the facility with staff member, Tinisha Sherley. The physical plant contained (4) four resident bedrooms and two and a half (2.5) bathrooms. The common nook area appeared to have live-in staff. Per facility sketch, facility should not attain any residents or staff to reside in that common area. LPA Flores requested the Plan of Operation for the facility to which the on-site caregiver was unable to locate. The facility has a dining room, kitchen, living room, and a gated backyard. Indoor and outdoor passageways were free of obstruction. There were no bodies of water located on the property. The facility has more than a two (2) day supply of perishable foods and seven (7) day supply of non-perishable foods. Water temperature measured at 120.4-degree Fahrenheit meeting within the required limits. Dishes and utensils were in sufficient supply and in good repair. Knives and sharp items are located in the kitchen in a locked cabinet. Resident bedrooms had the required bedding, furniture, and lighting. Disinfectants and cleaning solutions were secured in a locked cabinet in the kitchen. Centrally stored medication was located in a locked cabinet in the kitchen. The smoke and carbon monoxide detectors were tested and were observed to be operable. LPA's observed charged fire extinguishers mounted in the living room.



Staff files reviewed have a criminal record clearance and valid first aid/CPR certification. Resident files included but are not limited to signed admission agreements, appraisals, and needs and service plan. Per resident files reviewed, facility maintains three (3) out of four (4) residents that are under the age of 60, exceeding the Departments limitation of acceptance of residents under the age of 60. Facility sketch, personal rights, and emergency disaster plan is posted on a wall in the hallway near the entrance. According to caregiver, Tinisha, there are no firearms or ammunition on the premises.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Valerie FloresTELEPHONE: (951) 248-0308
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
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 3


Document Has Been Signed on 08/26/2024 06:16 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: ANGELIC HANDS ASSISTED LIVING
FACILITY NUMBER: 336426747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in three (3) out of four (4) residents are under the age of 60, exceeding the departments limitation of accepting a resident under the age of 60 in a resident care facility for the elderly (RCFE) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Discussion of POC will be determined at a later date. Conversation of the Plan of Correction will be notated on an LIC812.
Type B
Section Cited
CCR
87208(7)(a)
Personal Accommodations and Services


This requirement is not met as evidenced by:
(7) Sketches, showing dimensions, of the following:
(A) "Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used..."
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above due to staff residing in a common area (nook) that was not established in the facility sketch provided to CCL which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Submission of an updated plan of operation with an updated to facility sketch will be sent to CCL or the removal of staff belongings if Licensee chooses not to have live-in staff afterall.
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 StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Valerie FloresTELEPHONE: (951) 248-0308
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
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: ANGELIC HANDS ASSISTED LIVING
FACILITY NUMBER: 336426747
VISIT DATE: 08/21/2024
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During today's visit, deficiencies and technical violations were cited and a plan of correction was discussed. An exit interview was conducted, and a copy of this report was reviewed and provided to Caregiver, Tinisha.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Valerie FloresTELEPHONE: (951) 248-0308
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3