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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800118
Report Date: 05/13/2022
Date Signed: 05/13/2022 12:13:27 PM


Document Has Been Signed on 05/13/2022 12:13 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:
7603654620
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:15CENSUS: 13DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Steven RajadasTIME COMPLETED:
12:23 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Gardner met with Administrator Steven Rajadas who confirmed that there are currently no cases/exposures of COVID-19 within the facility. At the time of visit there were three (3) staff and thirteen (13) residents present.

LPA Gardner went over COVID-19 best practices for infection control and prevention with Steven Rajadas. The residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA Gardner observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, and social distancing. The facility has a designated infection control person who is responsible for ensuring that the facility is compliance with infection control practices. LPA Gardner requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in the bathroom cabinet. The facility has a limited supply of PPE. The facility was notified that they need to obtain a full 30-day supply of PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer. LPA Gardner inquired as to if staff have been fit tested for N95 masks and was told their staff have not been fit tested yet. LPA Gardner will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks and for not having a full thirty (30) day supply of PPE. All residents and staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

During today’s visit it was found that staff (S1) does not have a criminal record clearance.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ANGELIC MANSIONS
FACILITY NUMBER: 361800118
VISIT DATE: 05/13/2022
NARRATIVE
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S1 has been working at the facility for three (3) months. The facility will be issued a citation and a $500-dollar civil penalty for allowing S1 to work at the facility without a criminal record clearance.

Based on the observations made during today’s visit, one (1) type A deficiency was 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 Steven Rajadas, along with a copy of the TA Advisory Note, LIC809D, LIC811, LIC421BG, and the appeal rights.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/13/2022 12:13 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: ANGELIC MANSIONS
FACILITY NUMBER: 361800118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, and interview, the licensee did not comply with the section cited above by not obtaining a criminal background clearance for S1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2022
Plan of Correction
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The administrator has agreed to read regulation 87355 entirely and send LPA a self-certify letter that they have read and understood the regulation. The administrator has agreed get S1 criminal record cleared and to not allow S1 into the facility until they are obtain their criminal record clearance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022
LIC809 (FAS) - (06/04)
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