<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800118
Report Date: 08/02/2021
Date Signed: 08/02/2021 02:51:44 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210727134026
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: 15DATE:
08/02/2021
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Administrator's Phillip & Steven Rajadas TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident fell while in care.
Resident left on floor for extended period of time
Resident not provided comfortable temperature.
Facility is in disrepair.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Javina George made an unannounced visit to commence a complaint investigation as well as to deliver findings for the allegation(s) listed above. LPA met with Administrator's Phillip and Steven Rajadas and explained the purpose of the visit.

Allegation: Resident fell while in care.
LPA conducted interviews with Administrators Steve and Phillip Rajadas and it was confirmed that Resident #1 did have a fall on the weekend. Steven explained that the call system was temporarily not working and that staff was given the directive to check on the outside residents every 20-30 minutes. Per Administrator Staff #1 (S1) states that they did as they were told and that, when they went in to check on resident that they were laying on the floor. LPA reviewed communication logs that document R1 fell on 7/25/21, and had a bump and small laceration on the back of their head. R1 was recently moved to a different room following the incident, to keep an additional eye on R1. The allegation of Resident fell while in care is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210727134026

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: 15DATE:
08/02/2021
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Administrator's Phillip & Steven RajadasTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has insects.
Resident's call button does not work.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Javina George made an unannounced visit to commence a complaint investigation as well as to deliver findings for the allegation(s) listed above. LPA met with Administrator's Phillip and Steven Rajadas and explained the purpose of the visit.
Allegation: Facility has insects
LPA conducted a tour of the physical plant. LPA did not observe any insects on the interior nor exterior of the facility. LPA conducted interviews with staff and residents and all denied that there is an issue with insects at the facility. Therefore LPA was unable to corroborate the allegation, the allegation of facility has insects is UNSUBSTANTIATED.

Allegation: Resident's call button does not work
LPA requested staff to test resident #1 (R1) call button multiple times throughout LPA's visit. LPA observed that the call button to be operable. Once R1 pressed the button that is on a string that hangs on their neck an alert/ring is sent to the lab top and observed on the lap top the location and time that the call button was pressed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20210727134026
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANGELIC MANSIONS
FACILITY NUMBER: 361800118
VISIT DATE: 08/02/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 LPA observed multiple times throughout LPA's visit other resident's pressing their call buttons and staff responding. The allegation of Resident's call button does not work is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.


An exit interview was conducted and a copy of this report, was provided to Administrator's Phillip & Steven Rajadas.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20210727134026
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ANGELIC MANSIONS
FACILITY NUMBER: 361800118
VISIT DATE: 08/02/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Resident left on floor for extended period of time.
On 7/25/21 R1 sustained a fall where there was a bump, and laceration that was not bleeding on the back of R1's head. Steven explained that the call system was temporarily not working and that staff was given the directive to check on the outside perimeter residents every 20-30 minutes. Steven stated "to be honest that there is no way to tell how long R1 was left on the floor." There is an entry in the communication logs that revealed Staff #1 (S1), whom was on shift at the time of the fall, and made an entry reporting the incident however, the entry is vague and does not match with what was reported. Additionally in the communication logs reviewed in a different entry it states that R1 stated that they were on the floor calling for help for awhile. The allegation of Resident left on floor for extended period of time is SUBSTANTIATED.

Allegation: Resident not provided comfortable temperature.
LPA conducted a tour of the physical plant. LPA observed that the facility has three separate cooling systems, one for each side of the home. The thermostat where Resident #1 (R1) room is (left side, facing standing at the front door), revealed that it was 79 degrees inside, the current outside temperature at the time of the visit was 98 degrees. LPA did observe a ceiling fan that was not in use in R1s room. LPA conducted interviews and R1 stated that yes at times it does get warm inside of their room. Based on observation and interviews the allegation of Resident not provided comfortable temperature is SUBSTANTIATED.

Allegation: Facility is in disrepair
LPA conducted a tour of the physical plant and observed there to be old Christmas lights still hung, and one of the string of lights hanging down in the front of the facility. Also in the front entrance there were boxes on the table and patio furniture, bunched together. LPA observed in the backyard to certain areas of clutter: wheelchair, several boxes, trash cans, dolly, buckets, storage containers, and cat trees stacked in the backyard, up against the fence and the wall. Therefore the allegation of Facility is in disrepair is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.
An exit interview was conducted and a copy of this report, and appeal rights were provided to Administrator Steven Rajadas.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20210727134026
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGELIC MANSIONS
FACILITY NUMBER: 361800118
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2021
Section Cited
HSC
1569.269(a)(6)
1
2
3
4
5
6
7
1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on observation interview and record review the licensee failed to provide adequate care and supervision 1 out of 1 time. This poses an immediate health, safety and personal rights risk to persons in care.
1
2
3
4
5
6
7
The licensee agrees to relocate R1 so that staff can provide adequate care and supervision. The room change has already been made, nothing futher is needed.
Type B
08/16/2021
Section Cited
HSC
1569.269(a)(10)
1
2
3
4
5
6
7
1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental abuse... Based on observation, interview and record review the licensee did not ensure that R1 was not neglected 1 out of 1 times. This poses a potential health, safety and person rights risk to persons in care.
1
2
3
4
5
6
7
The licensee agrees to conduct an in-service on care and supervision. Proof is to be submitted to the department by 5pm, on the due date indicated.
Type B
08/16/2021
Section Cited
CCR
87303(b)(2)
1
2
3
4
5
6
7
87303 Maintenance and Operation
(b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. Based on observation, interview and record review the licensee did not ensure that the facility was kept at a comfortable temperature 1 out of 1 times. This poses a potential health, safety and person rights risk to persons in care.
1
2
3
4
5
6
7
The licensee agrees to conduct an in-service on heat induced illnesses and submit proof to the department by 5pm on the due date indicated.
Type B
08/16/2021
Section Cited
CCR
80087(c)
1
2
3
4
5
6
7
80087 Buildings and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. Based on observation, interview and record review the licensee did not ensure that the facility was free from obstruction 1 out of 1 times. This poses a potential health, safety and person rights risk to persons in care.

1
2
3
4
5
6
7
The licensee agrees to move the items to one of the 3 storage sheds on the property by 5pm on submit proof by virtual visit by the due date. Licensee will cotnact LPA by 5pm.
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 EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5