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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800118
Report Date: 07/01/2022
Date Signed: 07/01/2022 03:26:44 PM

Document Has Been Signed on 07/01/2022 03:26 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:ANGELIC MANSIONSFACILITY NUMBER:
361800118
ADMINISTRATOR:RAJADAS, SHEILAFACILITY TYPE:
740
ADDRESS:7585 WARREN VISTA AVETELEPHONE:
(760) 365-4620
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY: 15CENSUS: 11DATE:
07/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Steven RajadasTIME COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility for complaint control number 56-AS-20220628152115. During the complaint visit, LPA Gardner completed a case management visit to cite for deficiencies found during the complaint visit. LPA Gardner met with Administrator Steven Rajadas and explained the reason for the visit. At the time of the visit there were eleven (11) residents, and three (3) staff present.

During today’s visit, LPA Gardner found that the facility is using a condom catheter on resident (R1) overnight while the resident sleeps. The staff in the facility are placing the condom catheter on R1 prior to bedtime. The facility does not have does not have a physician’s order from hospice for the use of the condom catheter. The facility is also not qualified to place the condom catheter on R1.

LPA Gardner also found that Staff S1 has been working in the facility for two (2) months without obtaining a criminal background clearance. The facility will be receiving a citation and a $500-dollar civil penalty for allowing S1 to work in the facility without proper clearance.

During today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Administrator Steven Rajadas, along with a copy of the appeal rights.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2022
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 07/01/2022 03:26 PM - It Cannot Be Edited


Created By: Ryan Gardner On 07/01/2022 at 02:33 PM
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
, CA 92507

FACILITY NAME: ANGELIC MANSIONS
FACILITY NUMBER: 361800118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2022
Section Cited
CCR
87355(e)(1)

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87355.Criminal Record Clearance. (e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or
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The licensee has agreed to read regulation 87355 entirely and send LPA self-certify letter that the regulation was read and understood. The license has agreed to remove S1 from the facility and not allow S1 to work at the facility until S1 has a criminal background clearance.
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This requirement was not met based on evidence of observation and interview. LPA was informed that S1 has been working at the facility for two (2) months without a criminal background clearance.
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Type A
07/02/2022
Section Cited
CCR87623(a)(B)

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87623.Indwelling Urinary Catheter. (a)The licensee shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances: (B) A catheter shall only be inserted and removed by an appropriately skilled professional under physician's orders.
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The licensee has agreed to read regulation 87623 entirely and send LPA self-certify letter that the regulation was read and understood. The license has agreed that staff will stop the use of condom catheter. A catheter shall only be inserted and removed by an appropriately skilled professional under physician's orders.
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This requirement was not met based on evidence of observation and interview. LPA was shown the condom catheter in the resident’s bedroom closet. The Administrator admitted that staff puts the condom catheter on the resident at bedtime.
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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:Karen Clemons
LICENSING EVALUATOR NAME:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022


LIC809 (FAS) - (06/04)
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