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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800118
Report Date: 07/01/2022
Date Signed: 07/01/2022 03:23:54 PM

Substantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/28/2022 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220628152115
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
UNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Steven RajadasTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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9
Facility has an infestation of cockroaches.
Facility does not have hot water.
Resident(s) not being fed a sufficient amout of food.
Residents have access to toxic materials while in care.
Residents have access to sharp objects while in care.
Centrally stored medications are not kept in a safe and locked place.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility for the purpose of initiating an investigation and delivering findings for the above complaint allegations. 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 toured the facility, interviewed staff members, interviewed residents, and reviewed facility records.

For allegation, Facility has an infestation of cockroaches. LPA Gardner observed cockroaches in the hallway and in the living room area near a hole in the wall.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 56-AS-20220628152115
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
, CA 92507
FACILITY NAME: ANGELIC MANSIONS
FACILITY NUMBER: 361800118
VISIT DATE: 07/01/2022
NARRATIVE
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For allegation, Facility does not have hot water. LPA Gardner measured the water temperature in the bathroom at 102.5 degrees Fahrenheit. The water temperature in the bathroom is below the requirement of 105 degrees Fahrenheit.

For allegation, Resident(s) not being fed a sufficient amount of food. LPA Gardner was informed by the Administrator that the facility restricts food in between meals. If a resident requests food in between meals, the resident is told they need to wait until the next mealtime or snack time. The residents in care do not have limited dietary restrictions prescribed by a physician.

For allegation, Residents have access to toxic materials while in care. LPA Gardner found unlocked chemicals in the cabinet underneath the kitchen sink.



For allegation, Residents have access to sharp objects while in care. LPA Gardner found that knives were placed inside the kitchen pantry in an unlocked cabinet. There was also a knife left in a dish strainer on the kitchen counter.

For allegation, Centrally stored medications are not kept in a safe and locked place. LPA Gardner found that medication was placed inside the kitchen pantry in an unlocked cabinet.
Based on the information found and provided, the six (6) allegations listed above are deemed SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

During today’s visit, six (6) 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.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
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
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 56-AS-20220628152115
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
, 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)
Request Denied
Type A
07/02/2022
Section Cited
CCR
87303(e)(2)
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87303.Maintenance and Operation. (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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The licensee has agreed to read regulation 87303 entirely and send LPA self-certify letter that the regulation was read and understood. The license has agreed to adjust the facility water heater to meet the requirement of 105-120 degrees Fahrenheit.
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This requirement was not met based on evidence by observation. LPA measured the water temperature in the bathroom sink at 102.5 degrees Fahrenheit.
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Request Denied
Type A
07/02/2022
Section Cited
CCR
87555(b)(3)
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87555. General Food Service Requirements. (b)The following food service requirements shall apply: (3) Between-meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician.
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The licensee has agreed to read regulation 87555 entirely and send LPA self-certify letter that the regulation was read and understood. The license has agreed to allow residents food in between meals unless there is a dietary restriction prescribed by a physician.
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This requirement was not met based on evidence by interview of the Administrator. LPA was informed by the Administrator that the facility restricts food in between meals. If a resident requests food in between meals, they are told they need to wait until the next mealtime or snack time.
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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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 56-AS-20220628152115
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
, 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)
Request Denied
Type A
07/02/2022
Section Cited
CCR
87705(f)(2)
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5
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87705. Care of Persons with Dementia. (f)The following shall be stored inaccessible to residents with dementia: (2)Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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The licensee has agreed to read regulation 87705 entirely and send LPA self-certify letter that the regulation was read and understood. The license has agreed store toxic chemicals in a locked area that is inaccessible to residents.
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This requirement was not met based on evidence of observation. LPA observed an unlocked cabinet underneath the kitchen sink with toxic chemicals accessible to residents. LPA observed bleach and raid.
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Request Denied
Type A
07/02/2022
Section Cited
CCR
87465(h)(2)
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87465. Incidental Medical and Dental Care. (h)The following requirements shall apply to medications which are centrally stored: (2)Centrally stored medicines 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.
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The licensee has agreed to read regulation 87465 entirely and send LPA self-certify letter that the regulation was read and understood. The license has agreed store medications in a locked area that is inaccessible to residents.
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This requirement was not met based on evidence of observation. LPA observed an unlocked cabinet in the kitchen pantry with medication accessible to residents.
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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: 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
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 56-AS-20220628152115
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
, 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)
Request Denied
Type A
07/02/2022
Section Cited
CCR
87705(f)(1)
1
2
3
4
5
6
7
87705.Care of Persons with Dementia.(f)The following shall be stored inaccessible to residents with dementia: (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
1
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3
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The licensee has agreed to read regulation 87705 entirely and send LPA self-certify letter that the regulation was read and understood. The license has agreed store sharp knives in a locked area that is inaccessible to residents.
8
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14
This requirement was not met based on evidence of observation. LPA observed an unlocked cabinet in the kitchen pantry with sharp knives accessible to residents.
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Request Denied
Type B
07/08/2022
Section Cited
CCR
87303(a)
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7
87303. Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The licensee has agreed to read regulation 87303 entirely and send LPA self-certify letter that the regulation was read and understood. The license has agreed send LPA an action plan of how they plan to correct the hole in the wall, as well as pictures of the corrected hole in the wall. The licensee has agreed to send LPA statement proof of cockroach exterminator visits to LPA.
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This requirement was not met based on evidence by observation. LPA found cockroaches in the hallway and in the living room, as well as a hole in the wall in the living room.
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14
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: 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
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/28/2022 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220628152115

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
UNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Steven RajadasTIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
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9
Facility is unsanitary and in disrepair.
Resident's diapering needs are not being met.
INVESTIGATION FINDINGS:
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3
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5
6
7
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10
11
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility for the purpose of initiating an investigation and delivering findings for the above complaint allegations. 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 toured the facility, interviewed staff members, and interviewed residents.

For allegation, Facility is unsanitary and in disrepair. LPA found that the facility was clean and free of bad odor. The resident’s rooms were clean and free of bad odor. The resident’s bedroom linens were inspected, they were clean and in good repair.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
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.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 56-AS-20220628152115
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
, CA 92507
FACILITY NAME: ANGELIC MANSIONS
FACILITY NUMBER: 361800118
VISIT DATE: 07/01/2022
NARRATIVE
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For allegation, Resident's diapering needs are not being met. LPA Gardner found that the resident’s diapering needs are being met based on interviews with residents and staff.

Based on the information found and provided the allegations listed above are deemed 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 deemed unsubstantiated.

During today’s visit, no 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.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
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
LIC9099 (FAS) - (06/04)
Page: 7 of 7