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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005870
Report Date: 02/17/2022
Date Signed: 02/17/2022 03:03:38 PM

Document Has Been Signed on 02/17/2022 03:03 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ANGELIC DWELLING CARE HOMEFACILITY NUMBER:
306005870
ADMINISTRATOR:FAJARDO, RHOENAFACILITY TYPE:
740
ADDRESS:17709 BEECH STREETTELEPHONE:
(949) 413-3049
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 3DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Ana Millare - Caregiver
Gloria Oblefias - 		TIME COMPLETED:
03:15 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) Patricia Velazquez conducted an unannounced visit to Angelic Dwelling Care Home. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Caregiver Ana Millare. Caregiver Gloria Oblefias was also present. LPA Velazquez observed these 2 caregivers did not appear on the Facility Personnel Report Summary. LPA proceeded to call the Community Care Licensing Division (CCLD) Orange Regional Office to verify Criminal Record Clearance for these individuals. The facility is licensed for 6 non-ambulatory residents. The facility also has an approved hospice waiver for 4 residents. There are currently 3 residents living in the facility. The facility has a written emergency disaster plan.

At 1:28 PM LPA Velazquez conducted a tour of the physical plant along with Caregiver Millare. The 2 story home consists of 3 resident bedrooms with 2 bathrooms downstairs and 1 staff bedroom with 1 bathroom upstairs. LPA Velazquez asked Caregiver Millare if the facility had a signal system in accordance to Title 22 regulation and indicated the facility did not have a signal system. The 3 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed bed rails on one of the resident beds. LPA was informed that resident was receiving hospice services but passed away yesterday. Resident bath towels and personal hygiene supplies were adequately stocked. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 105.4 degrees Fahrenheit in the first bathroom and at 106.5 degrees Fahrenheit in the second bathroom. LPA Velazquez inspected the kitchen along with Caregiver Millare. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANGELIC DWELLING CARE HOME
FACILITY NUMBER: 306005870
VISIT DATE: 02/17/2022
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
26
27
28
29
30
31
32
 detectors were tested and found to be operational. Toxins, sharps, and medications were locked and inaccessible to residents. First aid kit was checked and found to be in order. The facility did not have a First Aid manual and LPA Velazquez advised Caregiver Millare to obtain an updated First Aid manual.

LPA Velazquez along with Caregiver Millare toured the outside grounds and no bodies of water were observed. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and the exit gate was operational. The auditory alarms were noted to be in operating condition. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit. LPA Velazquez informed Caregiver Millare to ensure a written physician's order for bed rails is present in a resident's file pursuant to Title 22 Regulation Section 87608 Postural Supports. LPA Velazquez also reviewed and provided a written copy of Title 22 Section 87303(i)(1)(A-C) Maintenance and Operation regarding Signal System requirements. Caregiver Millare acknowledged receiving a copy of said regulation.


Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. Civil penalties were also issued. An exit interview was conducted with Caregiver Ana Millare and a copy of this report along with the appeal rights and a copy of the LIC 9098 were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 02/17/2022 03:03 PM - It Cannot Be Edited


Created By: Patricia Velazquez On 02/17/2022 at 01:54 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ANGELIC DWELLING CARE HOME
FACILITY NUMBER: 306005870

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(i)(1)(A-C)

87303 Maintanence and Operation. (i) Facilities shall have signal systems which shall meet the following criteria:
(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit.
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 3 out of 3 bedrooms with 2 beds each which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
1
2
3
4
Licensee to ensure it complies with this section by installing a signal system pursuant to Title 22 regulation and submit written proof to LPA by POC due date.
Type A
Section Cited
CCR
87355(e)(1)
87355(e)(1) Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearnace or a criminal record exemption as required by the Department.

Deficient Practice Statement
1
2
3
4
Based on observation and interview the licensee did not comply with the section cited above in 2 out of 2 individuals which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
1
2
3
4
Licensee to ensure it complies with this section and obtain a Criminal Record Clearance for the 2 caregivers present at the facility at the time of this inspection and submit written proof to LPA by 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:Sheila Santos
LICENSING EVALUATOR NAME:Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3