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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881145
Report Date: 04/11/2024
Date Signed: 04/11/2024 12:33:13 PM


Document Has Been Signed on 04/11/2024 12:33 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:MILEY'S ANGEL HOME CARE, LLCFACILITY NUMBER:
361881145
ADMINISTRATOR:AZAULA, MILAGROSFACILITY TYPE:
740
ADDRESS:16510 GALA AVETELEPHONE:
(909) 428-1824
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY:6CENSUS: 5DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Licensee/Administrator Milagros AzaulaTIME COMPLETED:
12:45 PM
NARRATIVE
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On 04/11/2024 at 08:45 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there were three (3) staffs present, and five (5) residents present. Licensee/Administrator Milagros Azaula was contacted and informed of the visit. Licensee/Administrator Milagros Azaula arrived during the visit. LPA Brown explained the purpose of the visit to Licensee/Administrator Milagros Azaula.

The facility is a five (5) bedroom, two (2) bathroom home with a kitchen/dining area, living room, laundry area and a garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory residents, one (1) may be bedridden. The facility has six (6) Hospice Waiver. The current census is five (5) residents. LPA Brown was accompanied by Staff #2 (S2) to conduct a general overall inspection, which included, but was not limited to the following:


Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 77 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space and with sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms.

However, LPA Brown observed Resident #5 (R5) with half bed rail and no written order from R5's physician indicating the need for half bed rail for mobility. Deficiency will be issued.

***Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
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 7


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: MILEY'S ANGEL HOME CARE, LLC
FACILITY NUMBER: 361881145
VISIT DATE: 04/11/2024
NARRATIVE
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LPA Brown observed no appropriate signage of "No Smoking-Oxygen in Use" in Resident #3 (R3) room. Deficiency will be issued. LPA Brown measured and observed the water temperatures in the bathroom to be at 106 degrees Fahrenheit. The facility is equipped with operating smoke detectors, carbon monoxide alarms and charged fire extinguisher. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster and the disaster plan were posted in a common area. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked. However, LPA Brown observed residents medications pre-poured in a small container for the day, up to bedtime medication for each resident at the facility. LPA Brown explained that no medications shall be transferred between containers. Deficiency will be issued.

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility.

Care & Supervision: The facility has an administrator present in the facility. LPA Brown observed no staff scheduled to work at night (NOC) shift due to the facility having dementia residents. Deficiency will be issued

Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisal (LIC603) and needs and services plans (LIC625). The files were complete with updated physician’s reports, admissions agreements, needs and services plan and preplacement appraisals. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with negative tuberculosis (TB) result. LPA Brown observed files were complete. However, three (3) Medications/Medication Administration Records (MARs) were audited and LPA Brown observed that staffs at the facility are not updating residents MAR when dispensing residents medications. Deficiency will be issued.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D forms, LIC9102 and Appeal Rights were discussed and provided to Licensee/Administrator Milagros Azaula.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 04/11/2024 12:33 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: MILEY'S ANGEL HOME CARE, LLC
FACILITY NUMBER: 361881145

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by pre-pouring
residents medication for the day, transferring residents medication for the whole day in small containers which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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Licensee stated to train all staff on CCR 87465(h)(5) and submit proof of all staff training log to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not updating Resident #3 (R3), Resident #4 (R4) and Resident #5 (R5) Medication Administration Record (MAR) after dispensing their medications per R3, R4 and R5 physician's order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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Licensee stated to train all staff on CCR 87465(c)(2) and submit proof of all staff training log to LPA Brown on Plan of Correction (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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 04/11/2024 12:33 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: MILEY'S ANGEL HOME CARE, LLC
FACILITY NUMBER: 361881145

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)(4)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's a staff scheduled to work night (NOC) shift for night supervision to residents with dementia which poses which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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Licensee stated to train all staff on CCR 87705(c)(4)(A) and submit proof of all staff training log to LPA Brown on PLan of Correction (POC) due date.
Licensee stated to submit updated Personnel Report (LIC500) and Facility Staff Schedule showing a staff scheduled to work night (NOC) shift to LPA Brown on 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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 04/11/2024 12:33 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: MILEY'S ANGEL HOME CARE, LLC
FACILITY NUMBER: 361881145

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by having a half bed raile for Resident #5 without R5's physician's written order indicating the need for half bed rail for mobility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2024
Plan of Correction
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Licensee removed R5's half bed rail during the visit on 04/11/2024. Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not posting the required "No Smoking-Oxygen in Use sign" on Resident #3 (R3) room which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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LIcensee posted the required "No Smoking-Oxygen in Use" sign at R3's room during the visit on 04/11/2024. Plan of Correction (POC) cleared.
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7