374602552-9-19-2023-08-AS-RGAZ-CVTU8S-20230919152200

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602552
Report Date: 09/19/2023
Date Signed: 09/19/2023 03:22:05 PM

Document Has Been Signed on 09/19/2023 03:22 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ANGELS HAVEN II		FACILITY NUMBER:	374602552
ADMINISTRATOR:	FRENCH, CHRISTINE		FACILITY TYPE:	735
ADDRESS:	3949 BAJA VISTA DRIVE		TELEPHONE:	(760) 722-3955
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92054
CAPACITY: 6		CENSUS: 4	DATE:	09/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Administrator Christine French		TIME COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Riza Alvarez and Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were greeted and allowed entry into the facility by Staff Percival Basical, to whom LPAs discussed the purpose of the visit. Administrator Christine French arrived during the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) developmentally disabled adults, all of whom may be non-ambulatory. During today’s inspection, there was a total of three (3) clients in care; one (1) client was at a medical appointment.

LPAs, accompanied by the Administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant. Hot water temperature at taps accessible to clients were all compliant.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANGELS HAVEN II	FACILITY NUMBER: 374602552
	VISIT DATE: 09/19/2023

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per Administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers (3) were serviced within the last 12 months. First aid kits (3) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPAs interviewed staff and clients present. LPA interviews did not raise any licensing concerns. LPAs reviewed multiple staff and client records/files. Files reviewed contained required documents, except for one (1) document missing for one (1) staff. Confidential records were stored in locked areas. Administrator presented proof of current/active business liability insurance and surety bond.

A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC809-D page). A Plan of Correction was jointly developed with Administrator French.

An exit interview was conducted with Administrator Christine French, to whom copies of this report, the LIC809-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Riza Gloria Alvarez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2023 03:22 PM - It Cannot Be Edited

Created By: Riza Gloria Alvarez On 09/19/2023 at 03:12 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: ANGELS HAVEN II	FACILITY NUMBER: 374602552
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one (1) out of five (5) staff which poses a potential healthrisk to persons in care.
	POC Due Date: 10/19/2023
	Plan of Correction
1 2 3 4	Licensee will submit to CCLD a copy of completed LIC503 (Health Screening) for one (1) staff.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Denise Powell

LICENSING EVALUATOR NAME:

Riza Gloria Alvarez

LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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