361800441-12-18-2023-56-AS-ACON-CYMQ57-20231218105128

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361800441
Report Date: 12/18/2023
Date Signed: 12/18/2023 10:51:35 AM

Document Has Been Signed on 12/18/2023 10:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SPECIAL ANGELS GROUP FACILITIES INC		FACILITY NUMBER:	361800441
ADMINISTRATOR:	COLLIER, JAZMIN		FACILITY TYPE:	740
ADDRESS:	1053 N BRIERWOOD AVE		TELEPHONE:	(909) 543-7604
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	6	CENSUS: 5	DATE:	12/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jazmin Collier, Administrator		TIME COMPLETED:	11:00 AM

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	Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Special Angels Group Facilities, Inc. unannounced to conduct the Annual Inspection. LPA was greeted by Administrator, Jazmin Collier and granted entry. LPA introduced self and stated purpose of the visit. LPA signed in and was provided a seat to work at the dining table. During today's visit, LPA, accompanied by the Administrator, conducted a general inspection, which include, but was not limited to the following: Physical Plant - The facility is approved for 6 residents. The current census is 5. The facility maintains a Dementia Care Plan. LPA observed the facility to maintained at a comfortable temperature. Pathways throughout the facility's interior and exterior were free of obstructions. Each doorway included rails and ramp for residents to easily get in and out of the facility. LPA inspected four resident rooms. Each room included all required furniture such as sufficient storage space, proper lighting, bed fitted with regulatory linens, night stands and seating. There are 2 bathrooms. Each bathroom was equipped with handrails, non-slip grip rugs, and sufficient amounts of hand hygiene supplies. LPA observed a fully charged fire extinguisher near the kitchen; last inspected May 2023. The facility is also equipped with operable smoke/fire and carbon monoxide detectors. Posted throughout the facility in prominent places, LPA observed such as personal rights, resident council, LET-US-KNOW, Long Term Care Ombudsman and disaster/evacuation plans. LPA confirmed that cleaning supplies, toxins, sharp objects, and other dangerous items were secure and kept inaccessible to residents in care. LPA measured the water temperature in the kitchen; which measured between 98 and 105 degrees F. Medications, Resident and Staff files were secure in cabinets near the kitchen The facility maintains emergency food supplies and first aid kits readily available to those who may need it. Activities and snacks were seen in accessible areas for residents in care. Please see LIC9099-C

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SPECIAL ANGELS GROUP FACILITIES INC	FACILITY NUMBER: 361800441
	VISIT DATE: 12/18/2023

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Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care.. Facility offers a variety of foods and snacks to its residents in care. Sufficient amounts of dishes, cups, and utensils were observed stored properly.
Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. LPA observed, two, (2) staff members files which included criminal record/fingerprint background clearance through the department.
Record Review: LPA reviewed, two (2) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 2 staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Administrator certificate in good standing.

Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

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