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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880868
Report Date: 01/16/2024
Date Signed: 01/16/2024 02:37:36 PM


Document Has Been Signed on 01/16/2024 02:37 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:D&C ANGELS HOME CAREFACILITY NUMBER:
361880868
ADMINISTRATOR:RAMOS, LARIZA HOLCOMBFACILITY TYPE:
740
ADDRESS:1859 SHEDDEN DRIVETELEPHONE:
(909) 272-5355
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 5DATE:
01/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Lariza Holcomb Ramos - AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Lariza Holcomb Ramos, Administrator, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6) and a current census of (5) residents in care. The facility has a hospice waiver for (4) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. The facility's outdoor activity area is fenced and sufficient for residents. The facility's indoor activity area has sufficient lighting and is maintained at a comfortable temperature for residents. Resident’s bathrooms are operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured 118 to 119 degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. The facility has operating carbon monoxide alarms and telephone service. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Ombudsman poster, facility license, disaster evacuation plan and emergency telephone numbers.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9


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: D&C ANGELS HOME CARE
FACILITY NUMBER: 361880868
VISIT DATE: 01/16/2024
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Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Sharps, pesticides and other cleaning solutions were kept locked and stored away from food areas.

Care & Supervision: Facility has 24-hour staff supervision. Staff working have criminal record clearances or exemptions through the Department.

Record Review: Administrator's certification expires on 7/18/2024. LPA review of staff files reveal, staff #1 (S1) did not have a complete health screening with tuberculosis results on file. LPA review of resident files reveals, resident #1 (R1) did not have documentation of a complete preappraisal assessment on file.
Medical Related Services: The facility has a complete first aid kit with first aid manual. All medication is centrally stored and kept in a locked cabinet.

Based on LPA observations and record review, deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where reports LIC809, LIC809-D, and LIC9102 were discussed and copies with Appeal Rights were provided to the Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 01/16/2024 02:37 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: D&C ANGELS HOME CARE
FACILITY NUMBER: 361880868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by Staff #1 (S1) did not have a complete health screening with tuberculosis results on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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The Licensee/Administrator shall provide to the Licensing Agency proof of S1's tuberculosis results by POC due date

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: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 01/16/2024 02:37 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: D&C ANGELS HOME CARE
FACILITY NUMBER: 361880868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by resident #1 (R1) did not have documentation of a complete pre-admission appraisal on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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The Licensee/Administrator shall provide to the Licensing Agency an updated appraisal for R1 by POC due date.
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: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
LIC809 (FAS) - (06/04)
Page: 4 of 9