<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208789
Report Date: 12/05/2022
Date Signed: 12/05/2022 03:54:19 PM

Document Has Been Signed on 12/05/2022 03:54 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, 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: 6DATE:
12/05/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:46 PM
MET WITH:Ana Liza P ArateaTIME COMPLETED:
04:15 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
On 12/05/22, Licensing Program Analysts (LPAs) M. Medina and L. Salazar arrived to conduct an unannounced Case Management visit to follow up on three Hospice exception requests submitted by Licensee to the Department. On 10/26/22, the Department requested licensee to provide hospice care plans for each resident that a Hospice exception was made for.

LPAs toured the facility and observed residents in care. LPAs met with licensee who stated there is one out of six residents in care that are currently receiving Hospice care. Licensee does not have care plan available to provide to LPA.

Resident (R1) is currently receiving home health services for a prohibited condition. An exception request for the prohibited condition has not been submitted by licensee to retain this resident and prohibited condition has not been reviewed or approved by the Department.

The following deficiency is being cited on the attached 809-D, if not corrected, poses an immediate risk to the health and safety to resident's in care.

Exit interview conducted. A copy of this report provided to Licensee for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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 2
Document Has Been Signed on 12/05/2022 03:54 PM - It Cannot Be Edited


Created By: Melinda Medina On 12/05/2022 at 03:14 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SIMPLY CARING ANGELS LLC
FACILITY NUMBER: 157208789

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2022
Section Cited
CCR
87615(a)(1)

1
2
3
4
5
6
7
Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care
1
2
3
4
5
6
7
Licensee will submit an exception request to the Department for the prohibited condition that the licensee requests to retain. A care plan will be submitted with the expeption request by the Plan of Correction date.
8
9
10
11
12
13
14
facility for the elderly. (1)Stage 3 and 4 pressure injuries. **This was not met as evidenced by R1 has a Stage 3 pressure injury being treated by Home Health.
8
9
10
11
12
13
14
Type A
12/06/2022
Section Cited
CCR87608(5)(A)

1
2
3
4
5
6
7
5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.(A) Bed rails that extend the entire length of the bed are prohibited except for
1
2
3
4
5
6
7
Licensee will submit hospice exception request which includes a hospice care plan to Department for R1 by POC due date.
8
9
10
11
12
13
14
residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
**This was not met as evidenced by R1 has full bed rails and not on hospice
8
9
10
11
12
13
14
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Melinda Medina
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2