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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208789
Report Date: 10/07/2025
Date Signed: 10/07/2025 08:35:44 PM

Document Has Been Signed on 10/07/2025 08:35 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SIMPLY CARING ANGELS LLCFACILITY NUMBER:
157208789
ADMINISTRATOR/
DIRECTOR:		ANA LIZA P ARATEAFACILITY TYPE:
740
ADDRESS:608 WEST WASP AVENUETELEPHONE:
(760) 793-2307
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY: 6CENSUS: 4DATE:
10/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Administrator Ana Liza ArateaTIME VISIT/
INSPECTION COMPLETED:
08:30 PM
NARRATIVE
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Licensing Program Analyst's (LPA)'s Shawna Doucette and Daiquiri Boyd arrived at the facility unannounced to conduct an annual inspection. LPA's were granted entry by Staff Normita Garcia. Staff contacted Administrator via telephone who responded to assist with the visit.

A tour of the facility was conducted with the Administrator. The residence was set at 73 F temperature and free of passageway obstructions inside and outside.

Facility had a 7 day nonperishable food supply and two day supply of perishable foods. Cleaning supplies were locked in a cabinet above the washing machine and under the kitchen sink. Smoke detectors and carbon monoxide detectors were checked and properly working. Fire extinguishers were charged and had service dates of 05/29/25. LPA checked water temperature which measured at 106.6 F. Medication was locked in a kitchen cabinet.

Resident, medication and staff records were reviewed. Facility was administering an over the counter medication that was expired and not prescribed by physician for R1. Facility staff are utilizing a hoyer lift for R1 and do not have training. Staff are not logging resident responses for R1's PRN's that are administered.

Facility does not have restricted health care plans for R2's restricted health condition. R2's LIC 602 states resident cannot do own injections or glucose testing. R12s LIC602 states R2 requires special diet. Staff do not have training for restricted health conditions. R2 and R3 do not have current Home Health Care Plans. R4 does not have a Home Health Care Plan. Facility staff do not have training for R2 and R3 restricted health conditions.



NAME OF LICENSING PROGRAM MANAGER: Alexandria Walton
NAME OF LICENSING PROGRAM ANALYST: Shawna Doucette
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: SIMPLY CARING ANGELS LLC
FACILITY NUMBER: 157208789
VISIT DATE: 10/07/2025
NARRATIVE
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R3 was prescribed a medication R3 never received on June 18, 2025. R3 went back to the doctor on July 8, 2025, which lists R3's medication as a current medication. Medication list shows prescribed from doctor orders, however facility never centrally stored or the administered medication. R3 has a restricted health condition however it is unknown if R3 still requires care for the restricted health condition.


A copy of this report with plan of correction and appeal rights were provided to the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Alexandria Walton
NAME OF LICENSING PROGRAM ANALYST: Shawna Doucette
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC809 (FAS) - (06/04)
Page: 10 of 10
Document Has Been Signed on 10/07/2025 08:35 PM - It Cannot Be Edited


Created By: Shawna Doucette On 10/07/2025 at 06:42 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: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on (interview) (record review)], the licensee did not comply with the section cited above in not centrally storing or administering a medication for R3 that was prescribed on June, 18, 2025, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2025
Plan of Correction
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2
3
4
Licensee agrees to submit in writing a new procedure on how this regulation will by met and LIcensee will train staff on procedures by POC due date 10/8/25.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
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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.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Shawna Doucette
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2025 08:35 PM - It Cannot Be Edited


Created By: Shawna Doucette On 10/07/2025 at 06:42 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: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(d)
Adminstrator - 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.

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 in Administrator receiving numerous repeated citations, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2025
Plan of Correction
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Licensee will submit in writing how the facility plans on remaining in compliance to meet this regulation by POC due date
Type B
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

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 in staff not having training for R3's hoyer lift, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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Licensee agrees to conduct hoyer lift training and submit to LPA by POC due date 10/17/25
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Shawna Doucette
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 10/07/2025 08:35 PM - It Cannot Be Edited


Created By: Shawna Doucette On 10/07/2025 at 06:42 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: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87613(a)(2)(B)
General Requirements for Restricted Health Conditions
(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (B) Training shall be completed prior to the staff providing services to the resident.

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 in staff not having training for, R2 and R3's restricted health conditions, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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Licensee agrees to submit proof of training for R2's restricted health condition by POC due date 10/17/25
Type B
Section Cited
CCR
87465(c)(3)
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: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

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 in facility staff not logging response from R1 after administering PRN, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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Licensee agrees conduct a staff training for medication records by POC due date 10/17/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Shawna Doucette
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 10/07/2025 08:35 PM - It Cannot Be Edited


Created By: Shawna Doucette On 10/07/2025 at 06:42 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: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in administering an expired over the counter supplement to R1 that was not prescribed by a physician which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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Licensee agrees to submit a written statement on the understanding of the regulation and how this regulation will be met by POC due date 10/17/25
Type B
Section Cited
CCR
87463(i)
Reappraisals
(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making.

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 in R3 removing R3's restricted health condition and facility not obtaining a reappraisal regarding the change in condition, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2025
Plan of Correction
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3
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Licensee agrees schedule and submit an appointment date for R3 with R3's primary care physician to determine R3's updated condition by POC due date 10/10/25. Licensee will submit reappraisal after scheduled appointment.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Shawna Doucette
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 10/07/2025 08:35 PM - It Cannot Be Edited


Created By: Shawna Doucette On 10/07/2025 at 06:42 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: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87609(b)(4)
Allowable Health Conditions and the Use of Home Health Agencies
(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having current home health care plans for R1, R2 and R3 and not having a Home Health Care Plan for R4, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2025
Plan of Correction
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2
3
4
Licensee agrees submit care plans for R1, R2, R3 and R4 by POC due date 10/24/25
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.
Alexandria Walton
NAME OF LICENSING PROGRAM MANAGER:
Shawna Doucette
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
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