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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208789
Report Date: 08/11/2021
Date Signed: 08/12/2021 10:39:55 AM

Document Has Been Signed on 08/12/2021 10:39 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SIMPLY CARING ANGELS LLCFACILITY NUMBER:
157208789
ADMINISTRATOR:ANA LIZA P ARATEAFACILITY TYPE:
740
ADDRESS:608 WEST WASP AVENUETELEPHONE:
(760) 793-2307
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY: 6CENSUS: 5DATE:
08/11/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 AM
MET WITH:Licensee Ana Liza P ArateaTIME COMPLETED:
11:00 AM
NARRATIVE
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On 8/11/2021, Licensing Program Analyst (LPA)s Shawna Doucette and LIsa Salazar contacted Licensee Ana Liza P Aratea to conduct a Case Management visit. LPAs knocked on the door and there was no answer. Licensee responded to the facility about 15 minutes later. Licensee Ana Liza P Aratea allowed LPA's into the facility.

The purpose of today's visit was to check care and supervision. LPA's obtained information that there were no staff in the facility at night.

Licensee gave a false name of staff on duty and provided another staffs record for the staff on duty. Staff on duty was not fingerprint cleared.

Based on interviews conducted, tour of facility and records review, deficiencies and Civil Penalty are being issued in the areas evaluated and listed on the 809-D according to California Code of Regulations Title 22, Division 6 and Health and Safety Code.

An exit interview was conducted and Plan of Correction was reviewed and developed with the Licensee. Licensee was provided with a copy of this report and Appeal Rights.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2021
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 3
Document Has Been Signed on 08/12/2021 10:39 AM - It Cannot Be Edited


Created By: Shawna Doucette On 08/11/2021 at 06:33 AM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SIMPLY CARING ANGELS LLC
FACILITY NUMBER: 157208789

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2021
Section Cited
CCR
1569.17(b)(1)(A)

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Fingerprints and criminal records of individuals in contact with clients; exemptions; criminal records clearances(b) In addition to the applicant, the provisions of this section shall apply to criminal record clearances and exemptions for the following persons: (1)(A) Adults
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Plan of Correction POC Staff was immediately removed from the facility at the time of visit.
Civil Penalty was issued.
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responsible for administration or direct supervision of staff. This requirement was not met as evidenced by: Based on observation, interviews and record review staff 1 (S1) was not fingerprinted while caring for residents in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
08/12/2021
Section Cited
CCR87405(d)(1)

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Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(1) Knowledge of the requirements for
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Plan of Correction POC Licensee agrees to submit a statement of the understanding of this regulation by POC due date 8/26/21
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providing care and supervision appropriate to the residents. This requirement was not met as evidenced by: Based interview, record review and observation Licensee did not hire qualified staff (not fingerprinted, no evidence of training or staff records), which poses an immediate health, safety or personal rights risk to persons in care.
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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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/12/2021 10:39 AM - It Cannot Be Edited


Created By: Shawna Doucette On 08/11/2021 at 09:00 AM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SIMPLY CARING ANGELS LLC
FACILITY NUMBER: 157208789

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2021
Section Cited
CCR
87307(d)(6)

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Personal Accommodations and Services apply:(d) The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by: Based on obervation on 6/2/21 Licensee did not
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Plan of Correction POC Licensee cleaned room and cleared passageways.POC cleared at visit.
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keep passageways clear of obstruction in the enclosed covered patio located off of the family room and master bedroom which poses an immediate health, safety or personal rights risk to persons in care.
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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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021


LIC809 (FAS) - (06/04)
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