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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800118
Report Date: 06/18/2021
Date Signed: 06/18/2021 02:24:43 PM

Document Has Been Signed on 06/18/2021 02:24 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
RIVERSIDE, 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: 13DATE:
06/18/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George arrived at the facility unannounced to conduct a health and safety check. LPA was greeted and granted entry by Administrator Steven Rajadas. LPA George explained the purpose of the visit.

At 12:48pm upon LPA walking up the facility walk way. LPA observed the that the facility perimeter gates are secured with a lock that is typically used for locking up bikes. LPA George spoke with Administrator's Steven Rajadas whom stated that due there being an incident a couple of weeks ago, with a resident walking out of the gate and refusing to come back, the combination lock was placed on the fence. Administrator stated that the lock is used to promote safety and to prevent the resident's from wandering and getting hit by a car. The facility does have an approved dementia care plan. However LPA the facility's fire clearance dated 10/28/2014 does not state that the facility is approved for a secured perimeter, the facility did not request a waiver to have a secured perimeter.

Therefore a deficiency will be cited according to California Code of Regulations.

An exit interview was conducted and a copy of this report and appeal rights was provided to Administrator's Steven Rajadas.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2021
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 06/18/2021 02:24 PM - It Cannot Be Edited


Created By: Javina George On 06/18/2021 at 01:47 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
RIVERSIDE, CA 92507

FACILITY NAME: ANGELIC MANSIONS
FACILITY NUMBER: 361800118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2021
Section Cited
HSC
87705(i)(2)

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87705 Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.
This requirement is not met as evidenced by: Based on observation the licensee did not obtain prior approval for a secured perimeter on 1 out of 1 times. This poses a potential health, safety, and personal rights risk to person's in care.
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The licensee's shall submit a request for a secured perimeter and submit proof to the department by 5pm on the due date indicated.

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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:Joel Esquivel
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2021


LIC809 (FAS) - (06/04)
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