374602132-10-24-2024-08-AS-DNGN-DAD27B-20241024170829

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602132
Report Date: 10/24/2024
Date Signed: 10/24/2024 05:09:33 PM

Document Has Been Signed on 10/24/2024 05:09 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ANGELES PARADISE II ARF		FACILITY NUMBER:	374602132
ADMINISTRATOR/ DIRECTOR:	MARIA ANGIE ROSE		FACILITY TYPE:	735
ADDRESS:	583 MARIPOSA ST		TELEPHONE:	(619) 656-0062
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91911
CAPACITY: 5		CENSUS: 4	DATE:	10/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Caregiver Noe Contreras and Licensee Maria “Angie” Rose		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

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 (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Noe Contreras. LPA also met with Licensee Maria “Angie” Rose, who arrived later during the visit. According to the facility’s license, the facility has a maximum capacity of five (5) clients, of which all may be ambulatory or non-ambulatory, but none may be bedridden. Per LIC602 Physician’s Reports, staff interviews, and LPA observation: During today’s inspection, there were a total of four (4) clients in care, and all were non-ambulatory. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present. During today’s visit, LPA performed a welfare check on all clients in care, interviewed multiple facility staff, and reviewed records for all clients and active staff. LPA, accompanied by the Licensee, also toured the interior and exterior of the facility, and inspected all common areas and resident bedrooms. The facility was in good repair and bedrooms and common areas were clean, except for LPA observing one (1) live roach in the facility’s kitchen area. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. [CONTINUED ON LIC 809-C,1 of 2]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

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 6

Document Has Been Signed on 10/24/2024 05:09 PM - It Cannot Be Edited

Created By: Dang Nguyen On 10/24/2024 at 03:24 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANGELES PARADISE II ARF	FACILITY NUMBER: 374602132
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85095.5(b)(2)(C)

Infection Control Requirements

(b) In addition to subsection (a), when one or more clients in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a client who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around clients and annually thereafter. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and interviews, Licensee did not ensure that 4 of 4 active staff (S1 through S4) were trained in the proper use of all required PPE annually. This posed a potential health risk to persons in care.
	POC Due Date: 11/24/2024
	Plan of Correction
1 2 3 4	Licensee agreed to conduct PPE training for S1 through S4. The training will include hands-on practice and will cover: a) how perform an N-95 seal check, b) how to correctly don and doff surgical masks, N-95 respirators, face shields, gowns, and gloves, and c) how to set up and manage an isolation bedroom. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date.

Type B

Section Cited

CCR

80087(a)(1)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the Licensee did not keep the facility free of insects, which posed a potential health and personal rights risk to 4 of 4 clients (C1 through C4) in care.
	POC Due Date: 11/24/2024
	Plan of Correction
1 2 3 4	Licensee agreed to arrange for a professional pest management company to treat the facility's kitchen for roaches, and to enroll in quarterly preventative pest-control services thereafter. Licensee agreed to E-mail a copy of the pest control invoice(s) to LPA, by the 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:

Lizzette Tellez

LICENSING EVALUATOR NAME:

Dang Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 10/24/2024 05:09 PM - It Cannot Be Edited

Created By: Dang Nguyen On 10/24/2024 at 03:24 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANGELES PARADISE II ARF	FACILITY NUMBER: 374602132
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80072(a)(8)(B)

Personal Rights

(B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and manager interview, 1 of 4 clients (C3) had an AFO Brace postrual support, and Licensee did not ensure that there was a written order from C3's physician indicating the need for this device in the client's records. This posed a potential personal rights risk to persons in care.
	POC Due Date: 11/24/2024
	Plan of Correction
1 2 3 4	Licensee agreed to contact C3's physician and obtain a written order for C3's AFO Brace. Licensee agreed to contact SDRC and obtain a letter of endorsement for the device. Licensee agreed to submit to the CCLD San Diego Regional Office (CCLASCPSanDiegoRO@dss.ca.gov) an Exception Request Letter for C3's AFO Brace, along with both above documents as support, by the POC due date.

Type B

Section Cited

HSC

1565(b)

Other Provisions

(b) If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and interviews, Licensee did not ensure that 3 of 4 active staff (S2 through S4) received annual training on the facility's written emergency/disaster plan. This posed a potential safetly risk to persons in care.
	POC Due Date: 11/24/2024
	Plan of Correction
1 2 3 4	Licensee agred to update its existing LIC610D Emergency/Disaster Plan, and then retrain S2 thorugh S4 on it. Licensee agreed to E-mail the training sign-in sheet to LPA, by the 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:

Lizzette Tellez

LICENSING EVALUATOR NAME:

Dang Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 10/24/2024 05:09 PM - It Cannot Be Edited

Created By: Dang Nguyen On 10/24/2024 at 03:43 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANGELES PARADISE II ARF	FACILITY NUMBER: 374602132
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80092.2(a)(1)

80092.2 Restricted Health Condition Care Plan: “(a) If the licensee of an ARF chooses to care for a client with a restricted health condition…the licensee shall develop and maintain…a written Restricted Health Condition Care Plan. The Plan must include all of the following: (1) Documentation that the client and the client and the client’s authorized representative, if any, the client’s physician or a licensed professional designated by the physician, and the placement agency, if any, participated in the development of the plan.” This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and manager interview, Licensee did not ensure that 4 of 4 clients (C1 through C4), who each had a restricted health condition, also had a written Restricted Health Condition Care Plan that was jointly developed by the parties described in regulation. This posed a potential health risk to persons in care.
	POC Due Date: 11/24/2024
	Plan of Correction
1 2 3 4	Licensee, in consultation with the client and/or their authorized representative, their physician/nurse, and their SDRC social worker, will write a Restricted Health Condition Care Plan each for C1 through C4’s gastronomies. Licensee agreed to E-mail the Restricted Health Condition Care Plans for C1 through C4, with required signatures, to LPA, by the POC due date.

Type B

Section Cited

CCR

80077.2

80077.2 Care for Clients Who Rely Upon Others to Perform All Activities of Daily Living: “(b) Prior to accepting a client into care, the licensee shall complete the following: (2) A Needs and Services Plan, as required by the facility-specific regulations, that includes all of the following: (G) A description of the client-specific training that facility staff will receive.” This requirement was not met, as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and manager interview, for 4 of 4 clients (C1 through C4), who each relied upon others to perform all activities of daily living, Licensee did not ensure that the direct care staff assigned to them received client-specific training meeting regulatory requirements. This posed a potential health risk to persons in care.
	POC Due Date: 11/24/2024
	Plan of Correction
1 2 3 4	Licensee agreed to arrange trainings for S1 through S4 on the client-specific ADL care needs of C1 through C4, and the objective symptoms and circumstances which would require elevation to health care or other outside providers. These trainings will be provided by each clients’ health care provider (physician or nurse), physical or mental health therapist (if applicable), and social worker / placement worker, within their individual scopes of practice. Licensee agreed to E-mail the training sign-in sheet(s) to LPA, by the 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:

Lizzette Tellez

LICENSING EVALUATOR NAME:

Dang Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANGELES PARADISE II ARF	FACILITY NUMBER: 374602132
	VISIT DATE: 10/24/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

The facility’s ambient internal temperature was complaint at 75 F. Hot water temperature at taps accessible to clients were also in the required range. Appliances to preserve perishable food were compliant in temperature: Refrigerator was 40 F, and Freezers were both 0 F. For the staff, there was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. For the clients, who all relied on gastronomy feeding, there was also enough formula on-site to sustain them for at least seven (7) days.

There were no sharp objects, toxic chemicals/poisons, active fireplaces, or open-faced heaters accessible to clients. No pools or bodies of water were observed on the premises. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. Per the Licensee, no firearms or ammunition are kept at the facility. Fire detection system, carbon monoxide detector, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguisher was serviced within the last twelve (12) months. Required licensing postings were observed in visible areas of the facility. Fire/disaster drills were performed at required intervals. Reserve supplies of Personal Protective Equipment (PPE) were on site. Licensee presented proof of current business liability insurance.

During review of client records, LPA observed, and manager interview confirmed: Client #1 (C1), Client #2 (C2), Client #3 (C3), and Client #4 (C4) all relied on nutrition via gastronomy (“G-tube”). [See LIC811 Confidential Names List for a description of person identifiers used in this report.] Licensee possessed a CCLD-approved waiver to provide gastronomy care, and a nurse had trained the facility’s current caregivers on gastronomy care within the last year. However, Licensee did not possess/maintain a personalized Restricted Health Condition Care Plan for C1 through C4’s gastronomies, which had also been jointly developed with those clients’ physicians / licensed professionals and placement agency [i.e. San Diego Regional Center (SDRC)], as required. C1 through C4 were also clients on relied on others to perform all activities of daily living (“total care”). Regulation required the staff caring for such clients received client-specific training from the clients’ health care provider (physician or nurse) and social worker, within their assigned scope of practice, to cover the clients’ “needs and objective symptoms that indicate when the licensee is to obtain health care or other type of assistance.” Licensee’s staff had not yet received such client-specific training. [CONTINUED ON LIC809-C, 2 of 2]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANGELES PARADISE II ARF	FACILITY NUMBER: 374602132
	VISIT DATE: 10/24/2024

NARRATIVE

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[CONTINUED FROM LIC 809-C, 1 of 2] Additionally, C3 used/wore an “AFO Brace” to support their ankles; this device is defined and allowed in regulation as a “postural support” if prescribed by the client’s physician. However, Licensee did not possess a physician’s order for C3’s AFO brace, before it was used on C3, as was required.

During review of training records, LPA observed: Licensee did not have written proof that 4 of 4 active facility staff [Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), and Staff #4 (S4)] received training on PPE within the last year, as required. Licensee also did not have proof that S2 through S4 also received training on the facility’s written Emergency and Disaster Plan within the last year, as required.

Five (5) deficiencies were cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued Technical Assistance (TA) regarding staff training on contractures / range of motion exercises (refer to the LIC9202-TA page).

An exit interview was conducted with Licensee Rose, to whom a copy of this report, the LIC 809-D pages, the LIC 9102-TA page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today's visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC809 (FAS) - (06/04)

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